Inspection·December 7, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete first but there was no answer or call back. Surveyor asked if she had called the director of nursing for reassignments of her CNA's, V3 affirmed that she did, but that the director of nursing instructed her to go back to the resident to ask if she was abused or not. Surveyor asked when the last time she was trained on abuse prevention, V3 said she could not recall but that she received one after the incident happened. V4 CNA could not be contacted for interview and was terminated from employment for not meeting service standards. V7 executive director was requested for interview but failed to honor surveyor requests during the investigation.V8 interim administrator who created the internal investigation is no longer with the facility. Facility policy on abuse reads in part, The facility prohibits any form of resident abuse, neglect, or exploitation. Facility shall supervise staff in such manner as to attempt to identify inappropriate behaviors such as rough handling of residents, identifying escalating aggressive behaviors from residents, or imposed seclusion. Staff members shall use the care plan or resident assessment to monitor and identify resident needs and behaviors that have the potential for abuse. All employees are obligated to report knowledge of potential for abuse, neglect, or exploitation of a resident to their immediate supervisor. Physical abuse is the infliction of physical of pain or injury to the resident which includes, but is not limited to, hitting, slapping, pinching, and kicking. Event ID: Facility ID: 146199 If continuation sheet Page 2 of 4 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 12/07/2025 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)

F 0610 Respond appropriately to all alleged violations. 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 conduct a thorough and accurate investigation into an allegation of abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 3. The nurse on duty (V3) did not provide immediate protection by removing the alleged perpetrator (V4) from resident contact as required. Instead, the nurse attempted to reassign the CNA to a different resident until she was specifically directed by the Director of Nursing (V2 DON) to remove the CNA from the building. Additionally the facility failed to evaluate relevant evidence, and concluded that the allegation was unsubstantiated. These failures created a facility-wide potential for residents to be placed at risk for unrecognized and/or inadequately investigated allegations of abuse. Findings include:R1 is cognitively intact [AGE] year old with diagnoses including but not limited to Parkinson's Disease, Spinal Stenosis and Scoliosis and requires staff assistance for all activities of daily living. On 10/24/25 at 8:30 PM, R1 screamed to the hallway staff stating Help! Help! Someone help me she is hurting me! V3, Registered Nurse (RN) responded to the screams and observed V4, Certified Nursing Assistant (CNA) at the bedside providing care. R1 reported that V4 hit her arm and hand multiple times while performing care causing immediate pain. On 10/23/25 at 8:30 PM R1 yelled Help me, help me, she is hurting me! prompting V3 RN to respond. V3 found R1 distressed and removed V4 CNA from the situation and reported that V4 hit her several times which caused her pain. R1 explained to V4 that the sit-to-stand machine was improperly placed on her and that during the lifting process she was telling the CNA V4 she was in pain and to stop, yet she kept continuing the process and instead told the her to be quiet. During interviews on 12/5/25 at 11:45 AM , R1 consistently stated that V4 CNA struck her hand several times along with her arm. R1 stated, Yes I remember what happened, she (V4 CNA) hit me in the arm and my hand hard. I told her she was hurting me and she didn't stop. She was placing me on the sit-to-stand machine and putting this circular thing to go around my waist and when she was hoisting me up, it was hurting me because is was squeezing me in the wrong area and I told her to stop and she just kept going so I screamed stop, stop, stop! So instead of stopping she slapped my arm and hand several times and told me to stop screaming. She was angry with me and that frightened me. That's when the nurse finally came in and told her to move away from me and she (V4) left the room and somebody else came in and helped me. Witness statements and the resident's distress were not reconciled or analyzed using the regulatory definition of abuse which defines abuse by the willful infliction of physical pain, and does not require injury or malicious intent. On 12/5/25 at 11:59 am, V2 (Director of Nursing), indicated that the nurse V3 RN called her and gave the reason that she wanted to rearrange the CNA's because one of the CNA's (V4) was giving her a hard time. I told V3 RN that V4 (CNA) needs to be sent home immediately because she just wanted to rearrange the schedule instead of sending the CNA home. I did say to her if the resident said abuse and she said yes so I told V3 that what we are dealing with is allegation of abuse. I text the executive director (V7) but she did not text me back. I called back and talked to V3 again to ensure that V4 (CNA) left the building. Surveyor asked about R1, V2 indicated that the resident is cognitive and is not confused and did not have any history of similar allegations. Interview with V3 RN on 12/5/25 at 12:51 PM indicated she heard R1 screaming and heard, Help! Help! She is hurting me! so she went to R1's room immediately and observed V4 trying to put R1's socks on the resident. Surveyor asked if she had called the director of nursing for reassignments of her CNA's, V3 affirmed that she did, but that the director of nursing instructed her to go back to the resident to ask if she was abused or not. Surveyor asked when the last time she was trained on abuse prevention, V3 said she could not recall but that she received one after the incident happened. The facility's Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146199 If continuation sheet Page 3 of 4 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 12/07/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete investigation did not evaluate the resident's distress and immediate outcry as evidence; did not compare the CNA's denial against resident credibility assessment; and did not apply the federal definition of physical abuse, and justified the unsubstantiated finding with clear evidence. As a result, the facility reached a conclusion inconsistent with the regulatory criteria of abuse. V4 CNA could not be contacted for interview and was terminated from employment for not meeting service standards. V7 executive director was requested for interview but failed to honor surveyor requests during the investigation.V8 interim administrator who created the internal investigation is no longer with the facility. Facility policy and procedures for abuse prohibition reads in part but not limited to, Abuse is any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm. This includes mental abuse, physical abuse, verbal abuse, or any other actions within this definition. Mental abuse is the infliction of mental/emotional suffering. 'It includes, but is not limited to humiliation, harassment, intimidation. Physical abuse is the infliction of physical pain or injury to the resident. It induces, but is not limited to hitting, slapping, and also includes controlling behavior through corporal punishment, or the misuse of physical restraints. Verbal abuse is the use of oral or gestured language that willfully includes disparaging terms to residents within their hearing distance. Examples of verbal abuse include, but not limited to, threats of harm or saying things to frighten a resident. Mistreatment means inappropriate treatment of a resident. Event ID: Facility ID: 146199 If continuation sheet Page 4 of 4