Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Estates Of Evanston during CMS and state inspections, most recent first.
A resident with Type 2 DM, hemiplegia, and CKD had blood glucose checks and subcutaneous Humalog insulin injections performed by an LPN in a hallway near the nurses’ station, visible to other residents and staff, based on the resident’s stated preference. However, the resident’s comprehensive care plan did not address this preference, and the facility’s medication pass policy requires privacy for injections and blood glucose monitoring. The charge nurse and resident coordinator were unaware that the preference was not reflected in the care plan, despite the facility’s policy that care plans be individualized and revised based on resident preferences.
A resident with multiple chronic conditions, including CKD, type 2 DM, and hemiplegia, was observed to be dependent in ADLs and incontinent of bowel and bladder, with no active order for an indwelling urinary catheter and an MDS significant change assessment documenting no catheter use. However, the comprehensive care plan continued to state that the resident required an indwelling catheter with a future target goal date. The Resident Coordinator reported that she updates care plans when informed of changes, but she was not aware the catheter had been discontinued and did not revise the care plan, despite having completed the significant change MDS and despite facility policy requiring ongoing assessment and care plan revision based on changes in condition and treatments.
A resident was observed with an Ipratropium Bromide nasal spray stored at the bedside, which the resident reported using for allergies, while the resident’s daughter was unsure how the medication arrived there. An LPN and the DON both acknowledged that medications should not be stored at bedside or administered without a physician’s order, yet review of the medical record showed no order for this nasal spray. The DON also stated there was no available medication storage policy, despite an existing bedside medication policy requiring a physician order for bedside storage of inhalation medications.
An LPN failed to follow infection control practices by not performing required hand hygiene between medication administrations for two residents. After giving meds to one resident, the LPN did not clean his hands, then responded to another resident’s call light, provided care, and handled items on the tray table before returning to the med pass. He then prepared medications for another resident and only used hand sanitizer afterward. The ADON confirmed that facility policy requires hand hygiene before and after med administration, and the written Medication Pass Guidelines specify proper hand hygiene technique.
The facility failed to ensure safety during mechanical lift transfers by not having two staff present and using an incorrectly sized sling, affecting two residents. Both residents, alert and oriented, reported instances of being transferred with only one staff member, contrary to the facility's policy. The correct sling size was not used, compromising resident safety.
Failure to Ensure Privacy During Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain privacy during blood glucose monitoring and insulin administration for one resident. A nurse (V7, LPN) was observed performing peripheral blood glucose testing and administering 5 units of Humalog (insulin lispro) subcutaneously into the resident’s abdominal area in a hallway near the nursing station, where the resident was visible to other residents and staff. The resident reportedly preferred to have blood sugar checks and insulin injections in the hallway without privacy. The facility’s Medication Pass Guidelines policy, dated 04/19, states that privacy is required for injections and blood glucose monitoring. Review of the resident’s comprehensive care plan with the charge nurse (V8) showed there was no care plan addressing the resident’s stated preference to receive blood glucose monitoring and insulin injections in the hallway without privacy. The charge nurse acknowledged that this preference should have been addressed in the care plan. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, Type 2 DM, and chronic kidney disease, with active orders for blood glucose monitoring before meals and at bedtime and for scheduled Humalog and Lantus insulin injections. The resident coordinator (V9) stated she was not aware of the resident’s preference and agreed it should be reflected in the comprehensive care plan, and the facility’s care plan policy requires ongoing assessment and revision of care plans based on resident preferences.
Failure to Revise Care Plan After Discontinuation of Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing assessment and to revise and update an individualized comprehensive care plan according to a resident’s current condition and treatments. A resident admitted with diagnoses including cerebral atherosclerosis, CKD stage 4, type 2 diabetes mellitus, and hemiplegia/hemiparesis following cerebral infarction was observed lying in bed, dependent with ADLs and transfers, incontinent of bowel and bladder, awake, responsive, but confused. Observation and record review showed that the resident’s active physician orders did not include an indwelling urinary catheter, and a significant change MDS assessment documented that the resident did not use an indwelling catheter and was incontinent of bladder. Despite this, the comprehensive care plan still indicated that the resident required the use of an indwelling urinary catheter, with a target goal date months after the catheter had been discontinued. Staff interview revealed that the catheter had been discontinued on a specific date, but the Resident Coordinator, who stated she updates care plans for changes in condition and plan of care, was not aware of the discontinuation and had not updated the care plan. She acknowledged that she had completed the significant change MDS assessment but had not revised the care plan to reflect the discontinued catheter, contrary to the facility’s policy that requires ongoing assessment and care plan revision based on changes in condition, treatments, and goals.
Unauthorized Medication Found at Bedside Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and only kept at bedside with a physician’s order, as required by facility policy and professional standards. During observation, a resident was found with an Ipratropium Bromide nasal spray on the bedside table, which the resident stated was used for allergies. The resident’s daughter reported she did not know who brought the medication and suggested it may have come from the resident’s belongings from another place. Review of the resident’s physician orders showed no order for Ipratropium Bromide nasal spray. When the surveyor informed an LPN of the medication at the bedside, the LPN acknowledged that medications should not be stored at bedside and should have a physician’s order to be administered. The DON similarly stated that medications should not be at the bedside without an order and that all medications require a physician’s order for administration, and was informed there was no order for the nasal spray. The DON also reported there was no policy available for medication storage, although the facility’s Bedside Medications policy, revised 03/21, states that bedside storage may be allowed for certain forms (such as inhalation) only with a specific physician order. The resident had been admitted with diagnoses including primary osteoarthritis of the right wrist, post-surgical aftercare for genitourinary surgery, muscle weakness, need for assistance with personal care, insomnia, and essential hypertension, but none of the documented orders included the nasal spray found at bedside.
Failure to Perform Required Hand Hygiene During Medication Administration
Penalty
Summary
A deficiency occurred when an LPN failed to follow the facility’s infection prevention and control practices for hand hygiene during medication administration. On 12/16/25 at 9:48 AM, the LPN administered medications to resident R59 and did not perform hand hygiene afterward. Immediately following this, the LPN responded to resident R83’s call light, attended to the resident’s needs, turned off the call light, and handled items on the resident’s tray table, including a food plate cover and a cloth table napkin, which he then carried to the nursing station and handed to another staff member. The LPN then resumed the medication pass and prepared medications for resident R81 before finally using hand sanitizer, acknowledging when informed of the observation that he should have performed hand hygiene after administering medications to R59 and before preparing medications for R81. The ADON later confirmed that the LPN should have performed hand hygiene before and after medication administrations, consistent with the facility’s Medication Pass Guidelines policy, which requires hand hygiene before starting the med pass and specifies proper technique for soap-and-water and alcohol-based hand rub use. This deficiency affected two residents (R59 and R81) reviewed for infection control during medication administration, as the LPN’s sequence of actions involved direct resident care and handling of potentially contaminated items between medication administration tasks without appropriate hand hygiene, contrary to the facility’s written policy.
Deficiency in Mechanical Lift Transfer Safety
Penalty
Summary
The facility failed to ensure resident safety during transfers using a mechanical lift by not having two staff members present and using an incorrectly sized sling. Two residents, both alert and oriented with intact cognition, were affected by this deficiency. One resident, weighing 141 lbs, was transferred using a sling that was too large, as the appropriate small sling could not be found. The staff confirmed that the sling used was not the correct size and was possibly from the hospital, indicating a lack of proper equipment management. The resident reported that transfers sometimes occurred with only one staff member present, contrary to the facility's policy requiring two caregivers for mechanical lift operations. Another resident also reported being transferred with only one staff member at times, despite the facility's policy and care plan indicating that two staff members are required for mechanical lift transfers. The facility's mechanical lift user manual and policy both emphasize the importance of using the correct sling size and having two caregivers present to ensure safety. The failure to adhere to these guidelines compromised the safety of the residents during transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Evanston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Place | 0.4 mi | ★★★★★ | 0 | 0 |
| Warren Barr Lieberman | 0.6 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Skokie | 0.7 mi | ★★★★★ | 6 | 0 |
| Citadel Of Skokie, The | 0.8 mi | ★★★★★ | 4 | 0 |
| Three Crowns Park | 1.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.