Three Crowns Park

In the surveyor’s words

From the most serious findings on record at Three Crowns Park, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 7, 2025

  Based on interview and record review, the facility failed to ensure that 1 of 3 (R1) residents reviewed for abuse in the sample of 3 remained free from physical abuse. This failure resulted in a staff member striking R1's arm and hand and staff member screaming at the resident, causing R1 to cry out in physical pain and emotional distress verbalizing that she was being hurt and abused. 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. […]

• Actual harm, isolatedF689Jan 3, 2025

  Based on interview and record review the facility failed to transfer a resident in a safe manner. This failure resulted in R1 falling and sustaining lacerations to her right foot 3rd, 4th and 5th toes requiring sutures. Findings include: R1's Physician Order Sheet dated 1/25 show R1 has diagnoses that include chronic kidney disease, spinal stenosis and chronic pain. R1's careplan with initiated date of 9/26/24 show R1 is alert and oriented and able to verbalize her needs. High risk for falls due to impaired balance. R1's careplan under transfers show, - (R1) requires staff assistance with transfer due to decreased physical mobility, She requires staff assistance with transfers using sit to stand lift. […]

• No harm, potential for more than minimal, widespreadF610Dec 7, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF602Jul 21, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF880Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to follow contact isolation protocols by failing to place correct signage on resident room door regarding isolation precautions, they failed to ensure that a resident on contact isolation was placed in an appropriate room, and they failed to ensure that a resident's breathing mask was properly contained in accordance with infection control protocols. These failures applied to two (R3 and R4) of six residents reviewed for infection control. Findings include: R4 is [AGE] years old and have resided at the facility since 2019. […]