Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Aliya Of Evanston during CMS and state inspections, most recent first.
A resident with significant urologic and renal history and an indwelling catheter requested a catheter change due to urine overflow. An RN declined to perform the procedure and had an LPN from another floor insert the new catheter. After insertion, there was no urine output, but the LPN reassured the resident without further assessment, and the resident’s repeated call light use and phone calls for help over several hours went largely unanswered or were significantly delayed. When the RN later deflated the catheter balloon, blood gushed into the catheter tubing, bag, and onto the resident’s diaper and bedding, which the resident captured on video. The resident called 911 and was hospitalized, where imaging showed the catheter balloon inflated in the bulbar urethra with active bleeding and a distended bladder filled with blood and air, along with a marked hemoglobin drop and hemodynamic instability. Facility records lacked nursing progress notes describing the catheter insertion, absence of urine output, bleeding, or assessments during the critical time frame, despite policy requiring detailed catheter documentation and monitoring.
A resident with paraplegia and complex urologic history requested a new indwelling catheter due to urine overflow. An RN declined to perform the catheter change and had an LPN from another floor insert it; after insertion, there was no urine output, but the LPN reassured the resident instead of reassessing. Over several hours, the resident’s call light went unanswered, and multiple calls to the facility’s main line were delayed or not answered while the LPN later admitted he had fallen asleep. The RN and LPN discussed in the hallway who would address the problem, and when the RN finally deflated the catheter balloon, significant bleeding into the catheter bag, linens, and onto the resident occurred. The resident ultimately called 911 himself and was hospitalized with CT-confirmed traumatic urethral catheter placement, large-volume hematuria, and hemodynamic instability. There was no contemporaneous nursing documentation of the catheter insertion, lack of output, repeated calls for help, or bleeding, despite facility catheterization guidelines requiring detailed charting and follow-up for low output.
A resident with complex medical and behavioral health needs did not receive scheduled morning medications and reported the absence of nursing staff after breakfast, leading to feelings of abandonment and lack of safety. The resident also experienced rude treatment from a CNA when expressing concerns, indicating a failure to uphold resident rights to safety and dignity.
The facility failed to follow its pneumococcal vaccination policy requiring all new admissions to be screened and offered the pneumonia vaccine within the first week of admission. Record review showed that four residents with multiple chronic conditions, including CVA, type II DM, COPD, CAD, HTN, malnutrition, and mobility impairments, had no documentation that a pneumococcal vaccine was offered or given since admission. The Infection Preventionist reported that new admissions are not offered the pneumococcal vaccine upon entry but are instead intended to receive it at a later vaccine clinic, and also acknowledged that no such clinic had been held during the past six months, resulting in the residents not being offered the vaccine as required by facility policy.
The facility did not follow its psychotropic medication policy requiring informed consent before starting treatment, as two residents received antipsychotic medications (Quetiapine and Clozapine) for several days before consents were signed. Both residents had complex medical and psychiatric histories, including conditions such as DM, multiple fractures, schizoaffective disorder, toxic encephalopathy, and dementia. The Interim DON acknowledged that psychotropic orders should not be entered before consent and reported that consents were obtained during care plan meetings held days after admission, contrary to the written policy stating that consent must be obtained before entering the medication order into the record.
Surveyors identified a 16% medication error rate when two residents did not receive medications as ordered or per manufacturer instructions. One resident with osteoarthritis, asthma, and hypertension did not receive a prescribed inhaler dose that was nonetheless signed as given, did not receive an ordered oral medication that was unavailable, and had topical Voltaren Gel applied without using the dosing card, in unmeasured amounts, and not to all ordered sites. Another resident with a history of stroke and insulin-dependent type 2 DM received only the sliding-scale dose of insulin lispro instead of both the ordered standing dose and sliding-scale dose, with no documentation explaining the omission of the standing dose.
A resident with intact cognition and multiple medical conditions was transferred to the hospital for a psychiatric evaluation without being informed in advance or having the transfer properly documented. Staff failed to obtain and record a physician's order, did not document the behaviors leading to the transfer, and did not follow facility policy for communication and documentation during the discharge process.
Two cognitively intact residents with chronic health conditions engaged in repeated verbal abuse toward each other during group activities, including name-calling related to weight in both English and Spanish. Staff and other residents confirmed this was an ongoing issue, and while staff attempted redirection and supervision, these measures failed to prevent escalation and emotional distress. The facility did not implement effective interventions to stop the verbal abuse, contrary to its own abuse prevention policy.
Two residents were involved in an incident where one made racially charged and demeaning comments to another, causing emotional distress. Despite a history of aggressive and disruptive behavior by the perpetrator, staff failed to initiate a formal investigation or implement preventive measures, and the required reporting procedures were not followed.
A resident with multiple chronic conditions reported to the receptionist that another resident made a racially charged comment, but no formal investigation or report was initiated by facility administration, despite policy requiring immediate reporting of abuse allegations to the state agency.
A resident with multiple chronic conditions reported to the receptionist that another resident made a racially insensitive comment, but no formal investigation or documentation was initiated by facility administration, despite policy requiring all abuse allegations to be investigated.
The facility failed to ensure resident privacy by not having staff knock before entering rooms, affecting two residents. One resident, with multiple health issues, and another who is blind, reported staff entering without knocking or announcing themselves. Observations confirmed this practice, despite facility policy and management expectations to the contrary.
The facility failed to discard expired medications in the 2nd floor medication room, potentially affecting all 51 residents. A surveyor found an expired Tuberculin vial and a bottle of acetaminophen without an expiration date. A nurse confirmed the TB vial should be discarded after 30 days, as per facility policy.
The facility failed to follow its 3-compartment sink policy when a cook did not submerge a utensil in the quat solution for the required 60 seconds, using it again for food preparation. Additionally, two sandwiches were found without a label date, contrary to the facility's policy on labeling and dating foods. The Dietary Supervisor confirmed the importance of these procedures for food safety.
The facility failed to monitor refrigerator temperatures and food safety in residents' rooms, as evidenced by missing temperature logs and improper temperature settings. Observations revealed that refrigerators contained improperly labeled and undated food items, with some past their sell-by dates. Staff interviews indicated that housekeeping was responsible for monitoring, but the required documentation was not available.
A facility failed to refer a resident with a history of bipolar disorder and alcohol abuse for a Level II PASARR evaluation. The resident was admitted with a Level I determination indicating no Level II was required, despite documented mental health issues. The Admissions Director did not initiate a referral, and the Social Service Director acknowledged the need for a new Level I request. The resident exhibited aggressive behavior and depressive symptoms, highlighting the necessity for a comprehensive evaluation.
The facility failed to follow physician orders for oxygen administration and infection control protocols for two residents. One resident's oxygen cannula was improperly stored and outdated, and their oxygen saturation was below prescribed levels without corrective action. Another resident received oxygen at a higher flow rate than prescribed, with outdated equipment. The facility's policies were not adhered to, leading to these deficiencies.
A facility failed to follow proper infection control practices when a Nurse Practitioner exited a resident's room wearing an isolation gown, despite the resident being under droplet precautions for influenza A. The Acting DON confirmed that PPE should be removed inside the room, and facility documents supported this protocol.
A resident with bipolar disorder and dementia alleged that a CNA hit and fondled him. The facility's investigation found no evidence, citing the resident's confusion and lack of physical signs. However, the resident later provided a detailed account to a surveyor. The CNA was suspended but returned to work on a different floor. The facility's investigation may not have been thorough, as the administrator was unaware of additional allegations until informed by the surveyor.
A resident with moderate cognitive impairment and a high risk of falls was found without necessary fall prevention measures in place, including a non-functional call light and a missing floor mat. Additionally, the resident's wheelchair had a malfunctioning brake, potentially contributing to a recent fall. Staff confirmed the absence of these measures, which are outlined in the facility's fall prevention policy.
Failure to Assess and Manage Indwelling Catheter Leading to Traumatic Urethral Bleeding
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services for an indwelling urinary catheter for one resident, resulting in a prolonged period without assessment or intervention when the catheter was not draining. The resident, who was cognitively intact with a BIMS score of 15/15 and had significant urologic and renal diagnoses including paraplegia, cystitis with hematuria, hydronephrosis, acute kidney failure, and prior hematuria with stent placement, requested a new catheter when his urine was overflowing. An RN on duty declined to perform the catheter change and asked an LPN from another floor to insert the catheter. The LPN reported being very busy on his own floor but proceeded to insert a new indwelling catheter late at night. After the catheter insertion, the resident observed that no urine was draining and questioned whether the catheter was correctly placed. The LPN told him to give it time and drink water. Over the next several hours, the resident had no urine output and repeatedly sought help by using his call light and calling the facility’s main line multiple times, with delayed or no responses. At one point, the LPN admitted to the resident that he had fallen asleep. Eventually, the RN entered the room, deflated the catheter balloon, and blood immediately gushed into and over the catheter bag and onto the resident’s diaper and bedding. The resident documented the timing of his calls on his cell phone and recorded video showing significant blood in the catheter tubing, bag, and on his diaper. The resident ultimately called 911 himself and was transported to the hospital, where imaging showed the catheter balloon inflated in the bulbar urethra with free air and active extravasation, a distended bladder with a large amount of blood and air, and a significant drop in hemoglobin associated with hemodynamic instability. The facility’s records contained almost no nursing documentation of the catheter insertion, the absence of urine output, the resident’s repeated calls for help, the bleeding episode, or any assessments or interventions between approximately 11:30 PM and 3:00 AM. The DON, NP, Medical Director, and Administrator all confirmed that there were no progress notes from the involved nurses describing what occurred during that time, despite facility policy requiring documentation of catheter size, procedure, urine characteristics, and monitoring of intake and output, and despite a prior similar episode of catheter-related bleeding for this resident that had also resulted in a 911 call and hospital transfer.
Failure to Recognize and Respond to Catheter Complication and Resident’s Urgent Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had and demonstrated the competencies needed to recognize, assess, and respond to an acute change in condition and urgent calls for help for a resident with an indwelling urinary catheter. The resident, who is cognitively intact with a BIMS score of 15/15 and has diagnoses including paraplegia, urinary device management, cystitis with hematuria, hydronephrosis, acute kidney failure, and kidney/ureter calculi, requested a new catheter when his urine was overflowing. An RN on the unit declined to perform the catheter change and asked an LPN from another floor to insert the catheter. The LPN reported being very busy on his own floor, but proceeded to insert the catheter late at night. After insertion, no urine drained, and when the resident questioned the placement, the LPN told him to give it time and drink water. Over the next several hours, the resident experienced continued lack of urine output and repeatedly attempted to obtain assistance. He activated his call light without response, then called the facility’s main line multiple times, with calls documented on his cell phone. On one call, the LPN answered and asked for 25 minutes before coming; on another, the LPN later admitted to the resident that he had fallen asleep. The resident reported hearing the LPN and RN in the hallway discussing who would address the problem. Eventually, the RN entered the room, deflated the catheter balloon, and blood immediately gushed into and over the catheter bag, onto the sheets, diaper, and the resident. The RN appeared startled and called the LPN back into the room. The resident then made additional calls to the building line as bleeding continued, and when the nurses returned, he told them not to touch him and to call an ambulance. The resident ultimately called 911 himself, and paramedics arrived and transported him to the hospital. Hospital records documented a traumatic indwelling catheter insertion with CT imaging showing the catheter balloon inflated in the bulbar urethra with free air and contrast extravasation consistent with active bleeding, a distended bladder with a large amount of blood and air, and a hemoglobin drop from 13.2 to 6.5 with hemodynamic instability requiring ICU-level care. The facility’s Administrator later stated she was not aware of the severity of the injury until reviewing the hospital diagnosis of traumatic urethral bleeding. The DON reported that the RN had said she was not comfortable with male catheters and had asked the LPN for help, and that she was unsure what caused the bleeding. The NP believed the catheter had been inserted in the wrong place and not fully advanced. There were no nursing progress notes by either nurse documenting the assessment, catheter insertion, lack of urine output, resident’s repeated calls for help, or the bleeding episode between late night and early morning, despite facility policy requiring documentation of catheter size, procedure, urine characteristics, and resident response, and guidance to check for low output and notify a physician or NP when indicated. The only notes around the event were brief entries indicating the resident was sent to the hospital and later admitted for traumatic urethral bleeding, and the medical record contained no documentation that the resident had ever removed his own catheter.
Failure to Ensure Resident Safety and Timely Medication Administration
Penalty
Summary
The facility failed to ensure a resident's right to feel safe and secure, as required by its Residents Rights Policy. A male resident with multiple medical diagnoses, including cervical disc degeneration, asthma, diabetes, kidney failure, hypertension, dementia with behavioral disturbances, bipolar disorder, alcohol abuse, depression, and adult failure to thrive, reported not receiving his scheduled morning medications on Christmas Day. The resident stated that he typically receives his medications between 8:00AM and 9:00AM, but on the day in question, he had breakfast and did not receive his medications as expected. He also reported that there was no nurse present on the second floor until well after breakfast, which contributed to his feelings of abandonment and lack of safety. The resident further stated that when he voiced his concerns about the absence of a nurse and the delay in receiving his medications, a CNA responded rudely to him. This interaction, combined with the lack of timely medication administration and absence of nursing staff, led the resident to feel unsafe and unsupported in the facility. The facility's policy documents the right of residents to safety and protection from abuse and neglect, but these rights were not upheld in this instance.
Failure to Follow Policy for Timely Pneumococcal Vaccination of New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own pneumococcal vaccination policy by not screening and offering the pneumonia vaccine to new residents within the first week of admission. The facility’s policy, titled “Pneumococcal Vaccinations” and reviewed on 1/6/2025, states that all current residents or their responsible party will be screened and offered the pneumonia vaccine within the first week of admission and annually, if eligible. Record review showed that four residents’ immunization reports contained no documentation that a pneumococcal vaccine was offered or given since admission. These four residents included an older male with multiple diagnoses such as cerebral infarction, type II DM, obesity, epilepsy, sleep apnea, and acute kidney failure; an older female with rhabdomyolysis, protein calorie malnutrition, HTN, cellulitis, CAD, and depression; an older male with muscle disorder, gait and mobility abnormalities, lack of coordination, intracerebral hemorrhage, HTN, hemiplegia, dysphagia, and anxiety; and an older female with venous insufficiency, gait and mobility abnormalities, protein calorie malnutrition, acute respiratory failure, type II DM, and COPD. During an interview, the Infection Preventionist stated that the facility does not offer the pneumococcal vaccine to new admissions immediately upon entering the facility, but instead plans to offer them at a scheduled clinic at a later date. The Infection Preventionist further stated that in the six months in this role, no vaccine clinic had yet been held, confirming that pneumococcal vaccines had not been offered to these new residents in accordance with facility policy.
Failure to Obtain Informed Consent Before Initiating Psychotropic Medications
Penalty
Summary
The facility failed to follow its own psychotropic medication policy requiring residents or their representatives to be informed of risks and benefits and to provide informed consent before psychotropic medications are initiated. For one resident, an adult female with multiple diagnoses including type II DM, cellulitis of the face, multiple fractures, sleep apnea, hyperlipidemia, sciatica, alcohol abuse, schizoaffective disorder, and cocaine abuse, the Physician Order Summary Report showed that Quetiapine Fumarate, an antipsychotic, was started on 10/8/2025. However, the corresponding psychotropic consent form was not signed until 10/15/2025, meaning the resident received the antipsychotic medication for seven days prior to documented consent. For another resident, an adult female with diagnoses including toxic encephalopathy, dysphagia, cognitive communication deficit, need for assistance with personal care, multiple fractures, paranoid schizophrenia, and dementia, the Physician Order Summary Report showed that Clozapine was started on 9/9/2025. The psychotropic consent form for this resident was signed and dated 9/17/2025, indicating she received the antipsychotic medication for eight days before consent was obtained. During an interview, the Interim DON stated that orders for psychotropic medications should not be entered prior to obtaining consent and explained that she obtained consents for these residents at their care plan meetings, which are usually held 3–7 days after admission. The facility’s written policy states that once informed consent is obtained, the order will be entered into the medical record, which did not occur in these two cases.
Medication Administration Errors and Failure to Follow Physician and Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and according to manufacturer instructions, resulting in a 16% medication error rate (4 errors out of 25 opportunities) during observation of medication administration. One resident, an older female with bilateral primary osteoarthritis, asthma, and essential hypertension, had multiple medication administration errors. Her physician orders included Advair Diskus inhaled every 12 hours, spironolactone 50 mg orally once daily, and Voltaren Gel 1% applied to both knees and feet twice daily with a 2 g dose. During a medication pass, the RN did not administer Advair Diskus as ordered but documented it as given in the MAR and instead showed the surveyor an Incruse Ellipta inhaler. Spironolactone was also not administered because it was reportedly not available, despite being ordered previously, and there was no indication at that time that the MAR was properly documented to reflect it was not given. The same resident experienced errors with the administration of Voltaren Gel. The RN donned gloves and applied an unspecified “ample” or “desirable” amount of Voltaren Gel to each knee using his gloved hand, without using the dosing card supplied by the manufacturer to measure the ordered 2 g dose. The gel was not applied to the resident’s feet as required by the physician’s order, and the amount applied to the knees did not correspond to a measured 2 g dose. Manufacturer guidelines for Voltaren Gel specify that the proper amount must be measured using the dosing card, with the gel applied within the oblong area up to the appropriate gram line and then rubbed into the skin, but this process was not followed. Another resident, an older male with a history of cerebral infarction and type 2 diabetes mellitus with hyperglycemia, also experienced a medication administration error involving insulin lispro. His physician orders included a standing order to inject 4 units SQ with meals for hyperglycemia and an additional sliding scale order (2 units for blood glucose 150–199 mg/dL, 3 units for 200–249 mg/dL, etc., with instructions to call the MD if blood glucose exceeded 350 mg/dL). During observation, an RN administered only 2 units of insulin lispro when the resident’s blood sugar was 167 mg/dL, stating that she followed only the sliding scale and believed the 4-unit order was merely a reminder and that the two orders “go together.” There was no documentation in the progress notes explaining why the 4-unit standing dose was not given, despite the care plan indicating that diabetes medications were to be administered as ordered by the physician and monitored for side effects and effectiveness.
Failure to Inform and Document Resident Transfer for Psychiatric Evaluation
Penalty
Summary
The facility failed to follow its discharge and change in resident condition policies during the transfer of a cognitively intact male resident with multiple diagnoses, including osteoarthritis, diabetes, morbid obesity, and nicotine dependence. The resident was transferred to the hospital for a psychiatric evaluation without being informed in advance of the reason for the transfer, as required by facility policy. The resident reported being awakened in the early morning hours and told by a nurse that he was going to the hospital, but was not given an explanation. He initially refused the transfer and called 911, resulting in police involvement before he ultimately agreed to go to the hospital. Documentation in the resident's medical record was incomplete. There was no record of the physician's order for the transfer, no documentation of the behaviors that led to the decision, and no evidence that the resident was informed of the transfer or the reason for it. Staff interviews confirmed that while some steps may have been taken, such as obtaining a physician's order and informing the resident, these actions were not documented as required by policy. The facility's discharge and change in condition policies require notification of the resident and responsible party, physician involvement, and thorough documentation in the medical record, none of which were fully met in this case. The incident was triggered by reports of the resident being verbally aggressive toward other residents and staff, leading to a decision to initiate an involuntary petition for psychiatric evaluation. Despite the facility's stated process for handling such behaviors, including assessment by social services, administrative review, and physician orders, the required documentation and communication steps were not followed or recorded. The lack of documentation and failure to inform the resident in advance constituted a violation of both facility policy and resident rights.
Failure to Prevent Resident-to-Resident Verbal Abuse During Activities
Penalty
Summary
The facility failed to prevent and protect two residents from ongoing verbal abuse between each other during facility activities. Both residents, who are cognitively intact and have multiple chronic medical conditions, engaged in repeated name-calling, specifically using derogatory terms related to weight, in both English and Spanish. This behavior was observed during group activities such as smoking breaks and movie viewings, with both residents confirming their participation in the inappropriate exchanges. Staff interviews revealed that the verbal altercations between the two residents were a known, ongoing issue. Activity aides and the activity director reported that the residents frequently called each other inappropriate names, and while redirection was sometimes effective, it did not prevent escalation during the incident in question. On the day of the reported event, staff attempted to intervene by separating the residents, but the verbal abuse continued, resulting in one resident becoming very upset and expressing a desire for the name-calling to stop. Other residents and staff corroborated that the verbal abuse was a recurring problem and that one of the residents often intimidated both staff and other residents. Despite supervision during activities and previous attempts at redirection, the facility did not implement effective interventions to prevent further incidents. The facility's own policy defines verbal abuse as the use of disparaging or derogatory language, which was not adequately prevented in this case.
Failure to Investigate and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident (R3) from abuse by another resident (R2), resulting in emotional distress. R3, who had multiple medical diagnoses including osteoarthritis, diabetes, and morbid obesity, and was cognitively intact, reported that R2 made racially charged and demeaning comments to him in the dining room. R3 immediately reported the incident to the receptionist, who stated she informed the former administrator upon his arrival. However, there was no documentation or evidence that a formal investigation or report was initiated regarding this specific incident. Further review revealed that R2 had a documented history of escalating non-compliant behaviors, aggression, and vocalizing racial slurs towards other residents and staff, which had previously led to a referral for inpatient psychiatric evaluation. Despite this history, no preventive measures or immediate interventions were implemented to protect R3 or other residents. The current administrator was not made aware of the incident until after the fact, and both the administrator and the registered nurse confirmed that no formal investigation or report was conducted as required by the facility's abuse policy.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by policy. A resident with multiple diagnoses, including osteoarthritis, diabetes, morbid obesity, hyperlipidemia, and sleep apnea, reported an incident in which another resident made a racially charged comment, referring to him as a 'slave.' The resident, who was cognitively intact, was upset by the incident and immediately reported it to the facility receptionist. The receptionist stated that she informed the former administrator upon his arrival and was assured the matter would be addressed. Despite the report, no formal investigation or report was initiated regarding the incident. The former administrator denied knowledge of the allegation, and the current administrator confirmed that no investigation or report had been made. The facility's abuse policy requires immediate reporting of any abuse allegation to the Illinois Department of Public Health, but this protocol was not followed in this case.
Failure to Investigate Alleged Abuse Following Resident Complaint
Penalty
Summary
A resident with multiple medical conditions, including osteoarthritis, diabetes, morbid obesity, hyperlipidemia, and sleep apnea, reported an incident in which another resident made a racially insensitive comment, referring to the resident as a 'slave.' The resident, who was cognitively intact, was upset by the comment and reported the incident to the facility receptionist. The receptionist stated that she informed the former administrator of the complaint upon his arrival and was assured that the matter would be addressed. Despite the report, the former administrator later stated that he was not made aware of the allegation, and no formal investigation or documentation of the incident was initiated. The current administrator confirmed that no investigation or report was conducted regarding the incident. The facility's abuse policy requires that all incidents or allegations involving abuse be documented and investigated, but this protocol was not followed in this case.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to uphold the residents' right to privacy by not ensuring that staff knocked on the door before entering residents' rooms. This deficiency was observed in the cases of two residents. One resident, a male with a medical history including hypertension, sleep apnea, obesity, and chronic heart failure, expressed concerns about staff entering his room without knocking or announcing themselves. Another resident, who is blind and has undergone multiple eye surgeries, also reported that staff did not knock or introduce themselves, despite a sign on the door requesting this courtesy. During observations, a housekeeping staff member was seen entering the rooms of these residents without knocking, despite being aware of the requirement. Both residents had previously filed grievances about this issue, indicating a pattern of non-compliance with privacy protocols. Interviews with facility management, including the Nursing Manager, Regional Director of Operations, and Interim Director of Nursing, confirmed that staff are expected to knock and wait for a response before entering a resident's room. The facility's policy on residents' rights to privacy also mandates this practice.
Expired Medications Not Discarded in Medication Room
Penalty
Summary
The facility failed to discard expired opened medications from the 2nd floor medication room, which has the potential to affect all 51 residents residing in the facility. During a medication room inspection, a surveyor observed an open house stock Tuberculin purified Protein Derivative (TB) vial that was about 75-80% full in the medication fridge, with an open date of 9/26/24, indicating it was expired. Additionally, a bottle of house stock acetaminophen 500mg was found on the medication cart without an expiration date. During an interview, a Registered Nurse confirmed that the opened TB vial should be discarded after 30 days and expired medications should be returned to the return bin for pharmacy pick-up. The facility's policy and best practices document state that outdated drugs should be immediately withdrawn and disposed of according to drug disposal procedures.
Non-compliance with Sanitation and Food Labeling Policies
Penalty
Summary
The facility failed to adhere to its 3-compartment sink policy, as observed when a cook, identified as V13, did not submerge a used utensil in the Quaternary Ammonium Compounds (quat) solution for the required 60 seconds. Instead, the utensil was submerged for approximately 2 seconds before being used again to prepare food. This was confirmed by V13, who acknowledged the deviation from the standard procedure, which mandates sanitizing items in the quat solution for at least 60 seconds to eliminate bacteria. The Dietary Supervisor, V12, also confirmed the purpose of the procedure and the requirement for air drying. Additionally, the facility did not comply with its Labeling and Dating Foods Policy. During an inspection, two individually wrapped ham and cheese sandwiches were found without a label date. The Dietary Supervisor, V12, immediately labeled the sandwiches with the current date. V12 explained that prepared food is considered good for 72 hours and that labeling is essential to track the use-by date. The policy requires that all ready-to-eat, potentially hazardous food be re-dated with a use-by date according to safe food guidelines or the manufacturer's expiration date.
Failure to Monitor Refrigerator Temperatures and Food Safety
Penalty
Summary
The facility failed to monitor and maintain the temperature of refrigerator units in residents' rooms, as evidenced by the absence of temperature logs and improper temperature settings. During observations, it was noted that the refrigerators in the rooms of four residents did not have temperature logs, and the temperatures were either too high or too low, deviating from the facility's policy of maintaining temperatures between 32°F and 41°F. For instance, one refrigerator was found at 48°F, while another was at 14°F. Additionally, the refrigerators contained improperly labeled and undated food items, some of which were past their sell-by dates. Interviews with staff, including a Restorative Aide, a CNA, and the Housekeeping Director, revealed that housekeeping was responsible for monitoring the refrigerator temperatures. However, the Housekeeping Director was unable to produce the temperature logs when requested, indicating a lapse in documentation and monitoring procedures. The facility's policy requires daily checks of refrigerator temperatures and proper labeling and dating of food items, but these procedures were not followed, leading to the observed deficiencies.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation, which is required for individuals with serious mental illness or intellectual disabilities. The resident in question, identified as R27, was admitted to the facility with a PASRR Level I determination indicating that no Level II evaluation was required. However, the resident had a documented history of bipolar disorder and alcohol abuse, which should have prompted a Level II evaluation. The Admissions Director, V17, relied on the initial determination from the hospital and did not initiate a Level II referral, while the Social Service Director, V9, acknowledged that a new Level I should have been requested given the resident's mental health history. The resident's medical records revealed a history of bipolar disorder and recent hospitalization for alcohol abuse with withdrawal delirium. Progress notes indicated ongoing issues with aggressive behavior, anxiety, and depressive symptoms, which further underscored the need for a comprehensive Level II PASARR evaluation. Despite these indicators, the facility did not take the necessary steps to ensure the resident received the appropriate assessment, resulting in a deficiency in the facility's compliance with PASARR requirements.
Failure to Follow Oxygen Administration and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration and infection control protocols for two residents. For one resident, the oxygen nasal cannula was found on the floor and not stored in a plastic bag, and the oxygen humidifier was outdated. The resident's oxygen saturation was below the prescribed level, yet oxygen was not administered as required. The registered nurse acknowledged the need for proper storage and weekly changes of the nasal cannula and humidifier but did not take corrective action during the observation. For another resident, the oxygen was set at a higher flow rate than prescribed, and the nasal cannula and humidifier were not dated or changed weekly as required. The acting Director of Nursing confirmed the expectation for weekly changes and proper administration of oxygen as per physician orders. The facility's policy on oxygen safety and use was not followed, contributing to the deficiencies observed during the survey.
Failure to Follow PPE Protocols for Resident with Influenza A
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for a resident under droplet precautions. During unit rounds, a Nurse Practitioner was observed exiting a resident's room while still wearing an isolation gown, contrary to the facility's protocol that requires all personal protective equipment (PPE) to be removed before leaving the room. The resident in question had been diagnosed with influenza A and was under contact and droplet isolation. The Acting Director of Nursing confirmed that PPE should be removed inside the resident's room and acknowledged that the room should have been marked with both contact and droplet precaution signs. Facility documents reviewed also indicated that all PPE, except a respirator if worn, should be removed before exiting the patient room.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident with a history of bipolar disorder and dementia. The incident was reported on 11/8/24 when the resident claimed that a CNA had hit him on the shoulder and later fondled his genitals. The facility's initial investigation concluded that the abuse could not be substantiated due to a lack of physical evidence and the resident's mild confusion. However, the resident later provided a detailed account of the alleged abuse to a surveyor, describing the CNA's actions and physical appearance. The facility's administrator reported the incident to the state department and conducted interviews with staff and other residents, but found no corroborating evidence or complaints about the CNA. The CNA was suspended during the investigation but later returned to work, albeit on a different floor from the resident. The administrator expressed disbelief in the resident's claim of having encountered the CNA at another facility, as no such facility existed. The facility's policy mandates documentation and investigation of all abuse allegations, but the report indicates that the investigation may not have been comprehensive, as the administrator was unaware of the resident's additional allegations until informed by the surveyor.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention measures for a resident with a high risk of falls, as identified in their care plan. The resident, who has moderate cognitive impairment and requires substantial assistance for transfers, was observed without a floor mat in place, which is a specified precaution in their care plan. Additionally, the resident's call light was not functioning, preventing them from alerting staff for assistance. The resident's wheelchair was also found to have a malfunctioning brake, which could have contributed to a recent fall resulting in a vertebrae fracture. Interviews with facility staff confirmed the absence of necessary fall prevention measures. A registered nurse acknowledged that the resident's call light should be within reach and operational, and a fall mat should be in place at all times. The regional nurse consultant emphasized the importance of these measures in preventing injuries and falls. The facility's policy on fall prevention and management outlines the need to identify residents at risk and implement preventive strategies, which were not adequately followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,455 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Evanston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mather Evanston, The | 0.6 mi | ★★★★★ | 0 | 0 |
| Pearl Of Evanston,the | 0.9 mi | ★★★★★ | 5 | 0 |
| Alpine Care Of Evanston | 1 mi | ★★★★★ | 11 | 0 |
| Dobson Plaza | 1.6 mi | ★★★★★ | 0 | 0 |
| Three Crowns Park | 1.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.