Inspection·July 21, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of property as evidenced by R1's wallet being stolen while in the facility. This failure affected one (R1) of four residents reviewed for misappropriation of resident property. Findings include:Facility reported incident (FRI) dated 6/27/2025 documents: R1's wallet was returned to the facility's front desk by the postman who found it on the sidewalk several blocks away around 6 PM on 6/27/2025. R1 had not been out of the facility. R1's Family member was notified by the credit card company of unusual activity at a gas station, a telephone company, and a chicken restaurant. The card was then cancelled.R1's face sheet dated 7/17/2025 documents that R1 is an [AGE] year-old resident with diagnoses including but not limited to: Heart failure, heart valve replacement, hypertension, neoplasm of the breast, and hearing loss.R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has a Brief Interview for Mental Status (BIMS) score of 15/15, which suggests that R1 is cognitively intact.On 7/17/2025 at 12:20 PM, R1 said, I found out that I did not have my credit card when my wallet was found outside the building, and someone found it and returned it to me. I did not call the police, but someone in the building called the police. I never had any personal items lost or taken in the past; this is the first time. I just trusted that the facility would hire good people to care for us.Police report number obtained and read: R1, stated that her wallet was stolen while she was at a retirement home. She advised that the incident occurred earlier in the day at approximately 0900 hours. According to R1, she had purchased on Amazon using a credit card and then placed her wallet back into her purse. At the time, R1 was in a room where only one employee was present. R1 later discovered her wallet outside on the street near the facility. Upon recovering it, R1 found that only her credit card was missing; all other contents remained inside. R1 described the suspected employee as a female Black, possibly between 30 to [AGE] years old, but could not provide any further identifying information.On 7/17/2025 at 3:06 PM, V1 (Administrator/Abuse coordinator) said, the postman found a wallet outside the facility and brought it in on 6//27/2025 and gave it to the front desk. Someone took the wallet of R1, and I don't know who took it. R1 said that she was ordering something and requested the assistance of a staff member to read her card. I don't know who that staff was. R1 said that on the same day, her card went missing. R1 doesn't leave the building. R1 described that an African American stout female assisted her with care that day. V14 Certified Nursing Assistant was assigned to care for R1, but I cannot accuse anyone. V14 was prohibited from coming to work in the facility, and I called the staffing agency and notified them of the incident. The police were called, and they started the investigation, came to the building, checked the video footage, and said that they know V14 but don't have any criminal background for her. V1 said, Taking residents' belongings is considered misappropriation, that is why I reported it, and I implemented that all the agency staff read and sign the abuse policy before they start the shift. The new process started on 6/28/2025, and we are offering a safe Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146199 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146199 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Crowns Park 2323 McDaniel Ave Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)