Cycle 1
Health 2025-04-24 · Fire 2025-04-24
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Evanston, IL
Three Crowns Park
3-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2323 Mcdaniel Ave, Evanston, IL
(847) 328-8700
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
26
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Covenant Living
Operator or chain grouping
Approved since
2024-06-05
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
15 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.24
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.11
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.89
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.78
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
5.59
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
2.12
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
2.29
CMS adjusted RN staffing hours
Adjusted total hours
6.00
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Footnote 9,13 |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Footnote 9,13 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Footnote 9,13 |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Footnote 9,13 |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Footnote 9,13 |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 5.17% |
8.2%
3 pts worse
|
Numerator 9 · Denominator 174 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Footnote 9,13 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Footnote 9,13 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Footnote 9,13 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
89.6%
2.1 pts better
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 100.0% · 4Q avg 91.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
50.3%
42.5 pts better
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
6.5%
3.7 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.0% |
18.5%
16.5 pts better
|
19.6%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
22.8%
16.7 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 42.9% |
15.0%
27.9 pts worse
|
14.9%
28 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
1.1%
2.5 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 55.7% |
21.3%
34.4 pts worse
|
19.8%
35.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 55.7% |
| Percentage of long-stay residents with pressure ulcers | 15.6% |
5.2%
10.4 pts worse
|
5.1%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 17.4% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.4% |
68.8%
0.6 pts better
|
81.7%
12.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 51.6% · Q3 66.7% · Q4 89.4% · 4Q avg 69.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
14.0%
1.6 pts better
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 12.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.9% |
63.0%
0.9 pts better
|
79.7%
15.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 41.6% |
26.2%
15.4 pts worse
|
23.9%
17.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 41.6% · Observed 40.0% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-23 · Fire 2024-03-23
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-04-24
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-05-16
F · Potential for more than minimal harm
2024-03-23
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-09
F · Potential for more than minimal harm
2024-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-26
F · Potential for more than minimal harm
2024-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-03-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-02
Inspection history
Recent health citations
G · Actual harm
2025-12-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-07
F · Potential for more than minimal harm
2025-12-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-07
D · Potential for more than minimal harm
2025-07-21
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
G · Actual harm
2025-01-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-31
Penalties and ownership
What sits behind the stars
Ownership
Creaney, Janet
Corporate Officer · Individual
Cunliffe, Terri
Operational/Managerial Control · Individual
Cunliffe, Terri
Corporate Officer · Individual
Cunliffe, Terri
W-2 Managing Employee · Individual
Dye, Lisa
W-2 Managing Employee · Individual
Flewellen, Lorene
Corporate Officer · Individual
Justie, Jeannie
Operational/Managerial Control · Individual
Justie, Jeannie
Corporate Officer · Individual
Justie, Jeannie
W-2 Managing Employee · Individual
Malzahn, Elizabeth
W-2 Managing Employee · Individual
Manlove, Matt
Corporate Officer · Individual
Meo, Christina
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Westminster Place
Evanston, IL
5-star overall rating with 5-star inspections with 4 recent health deficiencies
#2
Citadel Care Center-Wilmette
Wilmette, IL
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Alden Estates Of Evanston
Evanston, IL
4-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
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