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 Alpine Care Of Evanston during CMS and state inspections, most recent first.
The facility failed to follow its abuse prevention policy by not updating an abuse assessment and care plan after a physical altercation between two residents. Although both residents were immediately separated, assessed, and sent to the hospital, one resident with multiple comorbidities, including CHF, CKD, Parkinson’s disease, malnutrition, and a sacral pressure ulcer, did not have an updated abuse assessment or an available abuse care plan after the incident. The Administrator, Social Service Director, and DON each confirmed that, per facility policy, abuse assessments and care plans must be updated after incidents or significant changes, but this was not done in this case.
A resident with blindness, history of falls, prior subdural hemorrhage, and documented need for substantial/maximal assistance with toilet transfers was admitted and identified by the DON as high fall risk, but was scored as low risk on the fall evaluation and had no documented fall care plan beyond a bed alarm. Family had informed staff that the resident required constant monitoring due to blindness. During a day when clinical students were present, a CNA and student assisted the resident to the bathroom where he urinated on the floor and was difficult to redirect, then returned him to his wheelchair and left. Later, the CNA assigned a student to assist with feeding; the resident requested the bathroom, and the student took him there and left him alone while seeking help to clean urine, without proximate staff supervision. The resident was then found on the bathroom floor with a puddle of urine, stating he slipped and fell, and hospital imaging later showed a subdural hemorrhage.
A cognitively intact resident with Meniere's Disease, PTSD, and metabolic acidosis reported that an LPN responded angrily to her repeated requests for assistance and medication, slammed a medication cup onto the bedside table, and used profanity while referring to her as a problem, which a CNA described as rude and unprofessional. The same resident stated that a CNA assisted her to a bedside commode without verbal guidance, did not use a gait belt, and left the room despite her request that he remain nearby. During a care plan meeting in the resident’s room, the Administrator allegedly told the resident and her husband that the facility was not a hotel and threatened they would be removed and banned if they continued to voice grievances, while also making comments about her health and food choices that the resident perceived as demeaning.
Surveyors found that multiple residents receiving oxygen therapy did not have their oxygen managed according to physician orders and facility policy. Several residents on continuous or PRN oxygen via nasal cannula had undated oxygen tubing, one had tubing tangled around a bed rail, and another had an empty humidifier bottle despite an order to check and maintain humidifier water. In one case, a resident was receiving oxygen without any corresponding physician order, while another resident had an oxygen order but no care plan addressing oxygen use. Staff, including an LPN, the DON, and a nursing consultant, acknowledged that oxygen tubing should be dated, humidifier bottles should contain water and be checked routinely, and that oxygen use requires a physician order and inclusion in the care plan.
Surveyors found that a resident had multiple topical medications stored at the bedside, including products brought from home, without corresponding physician orders and contrary to facility policy requiring secure storage. The resident reported that CNAs and a family member applied these medications, while the care plan documented resistance to prescribed treatments but did not address the resident’s wish to keep medications at bedside. In a medication room refrigerator, staff stored several residents’ medications with a broken thermometer, had incomplete temperature logs, and left an expired medication in active stock, despite policies requiring secure, temperature-monitored storage and prompt removal of outdated drugs.
A resident who was alert, oriented, and able to verbalize needs but had limited upper extremity mobility was observed in bed struggling to reach a call light that was tangled between the bed siderail and mattress. The resident reported trying to use the call light to contact nursing staff. An RN acknowledged having given the resident medications earlier and forgetting to ensure the call light was accessible afterward. The DON later confirmed that facility policy requires call lights to be within reach of residents who can use them at all times.
A resident with hemiplegia, hemiparesis, and a history of falls reported repeatedly asking to be transferred from bed to a wheelchair but stated CNAs said they would return and did not, leaving the resident in bed since therapy was discontinued. A CNA acknowledged it had been weeks since assisting the resident to a wheelchair and believed therapy had ended, while an LPN, Rehab Director, and DON all confirmed the resident had no bed restrictions and should be up per resident request or schedule, with existing orders and a care plan for transfer via mechanical lift with 2–3 staff. This resulted in the facility not honoring the resident’s right to self-determination and choice of daily routine as outlined in its resident rights policy.
Staff failed to follow catheter-related physician orders and facility policies for two residents. For one resident with urinary retention, BPH, obstructive uropathy, and functional quadriplegia, surveyors observed dark yellow-orange urine with sediment in the Foley tubing and a drainage bag that produced 1000 ml of urine when emptied, despite the CNA reporting the bag had been empty earlier, and the catheter in place was an 18 Fr with a 5 cc balloon instead of the ordered 18 Fr with a 10 cc balloon, contrary to policy requiring adherence to physician orders and drainage bag emptying at least every 8 hours. For another resident with quadriplegia and neurogenic bladder, surveyors twice observed the indwelling catheter drainage bag attached above the waist on the bed rail, even though the care plan and facility policy required the bag and tubing to be positioned below the bladder level to prevent backflow, and the LPN and DON both acknowledged that the bag should be kept below the waist.
A resident receiving enteral nutrition via G-tube did not receive care in accordance with physician orders and facility policy when an RN administered medication through the tube without verifying placement and used undocumented flush volumes. The feeding container lacked a start time, and the RN could not determine when the feeding had begun. The DON confirmed that staff are expected to verify tube placement before medication administration, ensure the feeding container is properly labeled with name, rate, and start time, and follow ordered and policy-based flush volumes, all of which were not followed in this instance.
Surveyors identified infection control deficiencies involving two residents. One resident with a JP drain to the groin had no EBP order, no EBP signage, and no EBP setup outside the room, despite a facility policy requiring EBP for residents with indwelling medical devices. In a separate incident, an LPN preparing a magnesium dose for another resident cut a 400 mg tablet into quarters, handled the pieces with bare hands, returned the unused portions to the stock bottle, and did not perform hand hygiene, contrary to the DON’s stated standard practice that medications should not be handled with bare hands and unused split tablets should be discarded.
The facility did not maintain an accurate daily nurse staffing posting at the front desk, as the form displayed an outdated date and had not been updated by the responsible receptionist, who reported forgetting to do so due to being busy with holiday activities. The administrator confirmed that the 24-hour nurse staffing information should be updated daily but acknowledged that there was no policy in place for daily nurse staffing posting, and the facility was unable to provide such a policy, potentially affecting all residents receiving care.
A resident with multiple health issues, including high risk for pressure ulcers, experienced both weight loss and the development of a new wound prior to discharge. Staff identified the new wound but did not notify the physician, nurse practitioner, or the resident's family, contrary to facility policy requiring immediate notification of significant changes in condition.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective interventions to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with necessary preventive measures not consistently applied.
The facility failed to maintain a clean and safe environment for residents, with observations of dust, residue, and soiling in resident rooms and care areas. Six residents, including those with dementia and Parkinson's disease, were affected. The DON confirmed the unclean conditions, which violated the facility's housekeeping and infection control policies.
A resident with multiple diagnoses, including a history of falls, experienced two falls while smoking due to inadequate supervision and assistance. The resident, who requires a wheelchair and has impaired cognition, was not provided with necessary support when he dropped his cigar, leading to falls. Facility policies on smoking supervision and fall prevention were not effectively implemented.
A resident with moderate cognitive impairment was physically abused by a CNA, who forcefully pushed and hit the resident. The incident was witnessed by an Activity Aide, but the facility failed to conduct a thorough investigation or document the incident properly. The resident's care plan was not updated, and the facility did not adhere to its abuse policy.
The facility failed to follow their identified offender policy by not performing criminal background checks within 24 hours of new resident admissions and not scheduling fingerprint-based criminal history record inquiries within 72 hours of receiving initial results for four residents. This failure affected the safety and well-being of all 89 residents currently residing in the facility.
Failure to Update Abuse Assessment and Care Plan After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy by not updating an abuse assessment and care plan after a resident-to-resident physical altercation. On 3/15/26, an altercation occurred between two residents, who were immediately separated, assessed head-to-toe by the nurse on duty, and sent to the hospital for evaluation; the MD and families were notified. The facility’s Administrator stated that, per facility abuse policy, abuse assessments and care plans must be updated at least quarterly, annually, and after any incident or significant change, and acknowledged awareness that this was not completed for one of the residents involved. The Social Service Director reported that social services is responsible for updating abuse care plans and abuse assessments after any incident or significant change and was unsure why this was not done for that resident. The DON confirmed that residents’ abuse care plans and assessments should be updated after an incident to reassess and identify abuse risk levels, in accordance with the facility’s abuse policy. The affected resident was an older adult admitted on 1/23/26 with multiple diagnoses including encounter for palliative care, anemia, hypothyroidism, unspecified protein-calorie malnutrition, hypokalemia, Parkinson’s disease, acute on chronic diastolic congestive heart disease, pleural effusion, GERD, sacral pressure ulcer, generalized edema, pneumonitis due to inhalation, and chronic kidney disease. This resident’s Social Service Assessment/abuse screener dated 1/27/26 indicated a low risk, but following the altercation, the resident’s abuse care plan was not available, and there was no updated abuse assessment documented. The facility’s written Abuse and Retaliation policy, revised 1/2026, states that the facility will identify, assess, and care plan appropriate interventions for residents with verbally or physically aggressive behaviors, and that residents who allegedly abused another resident shall be immediately evaluated to determine suitable therapy, care approaches, and placement, while victims will be examined and provided increased supervision and support. Despite these policy requirements, the facility did not complete or update the abuse assessment and care plan for the involved resident after the incident.
Failure to Adequately Supervise High-Risk Blind Resident During Bathroom Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and supervision for a newly admitted resident with known high fall risk and impaired safety awareness. The resident, an older male with diagnoses including difficulty in walking, unspecified cataract, history of falling, nontraumatic subdural hemorrhage, cerebral edema, hypertension, ADHD, and other conditions, was blind and required substantial/maximal assistance with toilet transfers per the MDS. The MDS also documented short- and long-term memory problems, yet the resident’s fall risk evaluation scored him as low risk, and there was no documented fall care plan or fall prevention interventions beyond a bed alarm. The family had informed staff upon admission that the resident required constant monitoring due to blindness. On the day of the incident, the resident had been in the facility less than 24 hours and was assigned to a CNA, with clinical students present on the unit. Earlier in the day, the CNA and a clinical student assisted the resident to the bathroom, where he urinated on the floor and was difficult to redirect, insisting he knew what he was doing. They cleaned him, dressed him, returned him to his wheelchair, and left the room. Later, during the lunch meal, the CNA directed the clinical student to assist the resident with feeding. The resident requested to go to the bathroom, and the clinical student took him there. The student then left the resident alone in the bathroom to get help to clean urine on the floor, and when staff returned, the resident was found on the bathroom floor with a puddle of urine present. The resident’s fall was unwitnessed, and he was found sitting on the bathroom floor with his head against the door. Vital signs were obtained, and no visible injuries were initially noted; the resident stated he slipped and fell while coming out of the bathroom. The DON later stated that clinical students cannot provide accurate monitoring and supervision and that proximate supervision requires facility staff to be physically present with students during direct care, but the resident had been left under the student’s care without such proximate staff supervision. The resident was subsequently sent to the hospital, where imaging showed a 7 mm subdural hemorrhage along the parieto-occipital convexity, with the report noting that in the setting of recent trauma, an acute hemorrhage could not be entirely excluded. The facility did not report the fall to authorities, citing uncertainty about whether the hemorrhage was acute and the resident’s prior brain-related history.
Failure to Maintain Resident Dignity During Care, Medication Pass, and Care Plan Meeting
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was treated with dignity and respect during care interactions and a care plan meeting. The resident, an adult with Meniere's Disease, PTSD, and Acute Metabolic Acidosis, reported that on 01/09/2026 an LPN responded to her call light after a delay of about 10 minutes, during which she had requested assistance to the bedside commode and medication for stomach, gas, and chest pain. The resident stated that the CNA who assisted her was a tall Black male who did not speak, did not provide instructions or guidance during the transfer, did not use a gait belt, and left the room despite her request that he stay nearby. She reported that when the LPN arrived, the nurse appeared very angry, slammed the medication cup onto the bedside table, and used profanity, telling her to “shut the f*** up” and referring to her as a “f***ing problem” and “that bitch” while speaking with the CNA outside the room. The resident demonstrated to surveyors how the pills were slammed down and described feeling afraid she would fall during the transfer. During a care plan meeting held in the resident’s room with the Administrator, DON, therapy staff, and nursing staff, the resident reported that the Administrator told her and her husband that “this is not a hotel” and threatened that she and her husband would be thrown out and banned from the facility if they continued to voice grievances or if her husband kept “screaming” at staff. The resident denied screaming at staff and expressed frustration about not receiving daily baths as requested and documented on a sign in her room, and about therapy being discontinued after she refused one session due to claustrophobia related to using the elevator. The Administrator acknowledged to surveyors that he may have commented that the facility was not a hotel and discussed the resident’s food choices in relation to his personal experience with diabetes, while denying that he threatened eviction or made derogatory remarks about her appearance. The CNA confirmed witnessing the LPN being rude and lacking professionalism toward the resident, though he could not recall exact words, while the LPN denied using profanity and attributed the resident’s behavior to anxiety and PTSD.
Failure to Manage Oxygen Therapy per Orders and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not obtaining required physician orders for oxygen, not dating oxygen tubing when changed, and not maintaining humidifier water bottles as specified in facility policy. During observation, one resident was found in bed on continuous oxygen at 3 LPM via nasal cannula with undated tubing that was tangled around the bedside rail; the LPN stated tubing should be free of tangles and dated weekly. This resident’s record showed diagnoses including COPD, pleural effusion, and palliative care, with an active order for continuous oxygen at 2–3 LPM and instructions to check the humidifier water level every shift. Another resident with a diagnosis including cerebral infarction was observed in bed on 3 LPM oxygen via nasal cannula with undated tubing; the LPN confirmed tubing should be dated. The active physician order for this resident specified oxygen at 3 LPM via nasal cannula for SpO2 below 90% every shift for shortness of breath, but there was no care plan formulated for oxygen use. A third resident with diagnoses including hemiplegia, hemiparesis, and muscle wasting was observed in bed on 3 LPM oxygen via nasal cannula with an empty humidifier bottle and undated tubing; the LPN stated tubing should be dated and humidifier water checked and replaced when empty. The physician order indicated continuous oxygen at 2 LPM via nasal cannula, and the comprehensive care plan documented oxygen therapy related to ineffective gas exchange and interstitial pulmonary disease with an intervention to give oxygen as ordered. A fourth resident with diagnoses including hemiplegia, hemiparesis, and paroxysmal atrial fibrillation was observed in bed on 2.5 LPM oxygen via nasal cannula with undated tubing, and review of the active physician order sheet showed no order for oxygen use, although the comprehensive care plan included a plan for oxygen usage. The DON and a nursing consultant later confirmed that oxygen tubing should be dated when changed, humidifier bottles should be checked and refilled as needed, and that residents using oxygen should have a physician order and be care planned, consistent with facility policies on oxygen therapy and physician orders.
Improper Medication Storage and Use of Unordered Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored securely and used only in accordance with physician orders and facility policy. During wound care for R7, surveyors observed multiple topical medications kept at the bedside, including ketoconazole 2% cream, zinc oxide 4%, triamcinolone 0.1% ointment, and mupirocin 2% ointment. The Wound Care Nurse stated that treatment medications should not be kept at the bedside without a physician order but acknowledged that R7 requested to keep them there and that R7’s son had brought some medications from home. R7 reported that CNAs applied these medications to his buttocks after incontinence episodes and that his son also applied them during visits. Record review for R7 showed active physician orders for mupirocin 2% cream and triamcinolone 0.1% cream for specific wound care sites and frequencies, but no orders for ketoconazole 2% cream or zinc oxide 4%. The DON confirmed that the ketoconazole and zinc oxide had been brought in by a family member and that residents could not keep treatment medications at the bedside without physician orders. R7’s comprehensive care plan documented that he resists care, refuses to follow physician orders and guidance, and believes his own treatment approaches are more beneficial than those recommended by health care professionals. He was identified as high risk for pressure sore development, with contributing conditions including arthropathic psoriasis and seborrheic dermatitis, but the care plan did not address his desire to keep medications at the bedside. Surveyors also identified medication storage issues in the third-floor medication room refrigerator, where medications for several residents were stored with a broken thermometer and an incomplete temperature monitoring log for two months. An expired medication, Konvomep (omeprazole) 2-84 mg/ml, labeled as opened on 8/28/2025 and expired on 9/27/2025, remained in the refrigerator for one resident. The RN on duty stated he was unaware the thermometer was broken and that the night shift nurse completed the refrigerator log. Facility policies required medications to be secured in locked storage, to be administered only with written physician orders, to be stored at appropriate refrigerated temperatures with daily temperature logs, and for outdated or deteriorated medications to be immediately removed and disposed of, but these procedures were not followed in the observed instances.
Call Light Not Kept Within Reach for Resident With Limited Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by policy. During observation on 12/2/25 at 10:46 AM, a resident who was alert and oriented x3, able to verbalize needs, and had limited upper extremity mobility was found lying in bed attempting, but struggling, to reach a call light that was tangled between the bed siderail and mattress. The resident stated he was trying to reach the call light to call for his nurse or CNA. When the surveyor notified the assigned RN at 10:50 AM and showed her the situation, the RN acknowledged she had administered the resident’s medications that morning and had forgotten to ensure the call light was accessible. The RN then had to lift the mattress to remove the tangled call light. Later that day, the DON confirmed that residents’ call lights should be within reach and accessible at all times, consistent with the facility’s call light policy revised on 6/30/25, which states that call lights must be placed within reach of residents who are able to use them at all times. This sequence of events demonstrates that the resident’s needs and preferences for accessible communication with staff were not reasonably accommodated when staff failed to position the call light within the resident’s reach after providing care, resulting in the resident being unable to independently summon assistance.
Failure to Honor Resident Choice to Get Out of Bed After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding daily routines, specifically the resident’s request to get out of bed and into a wheelchair. On 12/2/2025 at 11:15 a.m., Resident 18 reported that she asked every day to be placed in her wheelchair, but CNAs told her they would return and did not come back until later, and that she had not been out of bed since her therapy was discontinued a couple of weeks prior. A CNA stated at 11:20 a.m. that she had assisted the resident out of bed when the resident was in therapy, but it had been weeks since she last assisted the resident to her wheelchair and she believed the resident was no longer in therapy. An LPN stated at 11:25 a.m. that the resident should be out of bed as requested by the resident or according to a schedule for being up in a chair. On 12/3/2025 at 1:00 p.m., the Rehab Director confirmed that the resident had no bed restrictions and could be out of bed as requested by the resident or per a schedule, and that the resident received PROM (passive range of motion) to all extremities. Earlier that day at 10:30 a.m., the DON stated that all residents should be out of bed per a schedule, therapy, or resident request, and that no one should remain in bed solely because therapy was completed. Record review showed that the resident had diagnoses of hemiplegia and hemiparesis and a history of falling, with orders dated 4/22/2025 for nursing rehab transfer to a manual wheelchair via full body lift with 2–3 staff for safety, and a care plan dated 1/25/2025 specifying transfer via mechanical aid, lift sling, and 2 staff for transfers. An occupational therapy discharge summary indicated the highest practical level had been achieved. Despite these orders and the facility’s written policy on resident rights and self-determination, the resident’s expressed choice to get out of bed and into a wheelchair was not being consistently honored after therapy was discontinued.
Failure to Follow Catheter Orders and Positioning Requirements
Penalty
Summary
Surveyors identified that staff did not follow physician orders and facility policies for indwelling urinary catheter management for two residents. For one resident with diagnoses including urinary retention, functional quadriplegia, benign prostatic hypertrophy, obstructive and reflux uropathy, and kidney calculi, observation during wound care showed catheter tubing with sediment draining dark yellow-orange urine and a drainage bag that yielded 1000 ml of urine when emptied, despite the CNA stating the bag had been empty at the start of the morning shift. Review of the medical record showed an active physician order for an 18 Fr Foley catheter with a 10 cc balloon and catheter care every shift, but the resident was found to have an 18 Fr catheter with a 5 cc balloon in place. Facility policies required adherence to physician orders and emptying catheter drainage bags at least every 8 hours, with accurate recording of urinary output, but the drainage bag had not been emptied by the end of the night shift as required. For another resident with quadriplegia, neurogenic bladder, functional quadriplegia, and chronic multiple wounds, surveyors twice observed the indwelling urinary catheter drainage bag attached to the upper bed railing above the resident’s waist. The LPN present acknowledged that the drainage bag should be placed below the waist to prevent backflow and then repositioned the bag. The DON later confirmed that all indwelling catheter drainage bags should be placed below the waist. The resident’s admission record and care plan included an order for an indwelling catheter size 16 Fr with a 10 ml balloon for neurogenic bladder and an intervention to position the catheter bag and tubing below the level of the bladder. The facility’s indwelling catheter policy stated that the catheter bag will always be positioned below the bladder region to prevent backflow when the Foley bag has no anti-backflow valve, but this was not followed for this resident.
Failure to Follow Enteral Feeding and G-Tube Medication Administration Protocols
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and physician orders for enteral (tube) feeding management and medication administration for one resident with a G-tube. During an observation, an RN administered a medication via the resident’s enteral tube without checking tube placement beforehand. The nurse acknowledged that she did not verify placement, despite stating that tube feeding placement should be checked prior to medication administration using a pH strip or by aspiration. The tube feeding site was covered with a clean, dry dressing, but no other placement confirmation was identified. The tube feeding bottle was infusing at 50 mL/hr, but the container did not have a visible start time, and the nurse stated she could not determine when the feeding had been started, noting that there should be a start time of infusion. The RN also flushed the tube with 60 mL of tap water before administering the medication and 90 mL of water afterward, explaining that she gives extra flushing because the resident does not drink water. The DON later stated that nurses should check tube placement before medication administration, that the tube feeding container should include the resident’s name, rate, and start time, and that tube feedings should be flushed according to the physician’s order and facility policy. The physician’s order specified Jevity 1.2 at 50 mL/hr starting at 3 p.m. for 21 hours or until 1050 mL is reached per day, with a 150 mL flush every 6 hours. Facility policies required that feeding bags be labeled with the date and time feeding was started, that G-tube placement be checked by tube marker location and gastric content aspiration with pH confirmation, and that the G-tube be flushed with 15–30 mL of water before and after medications. These requirements were not followed during the observed medication pass.
Failure to Implement Enhanced Barrier Precautions and Safe Medication Handling
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to both enhanced barrier precautions (EBP) and medication handling. One resident, R96, was observed lying in bed with family at the bedside with no EBP signage posted and no EBP setup outside the room, despite having a Jackson-Pratt (JP) drain to the right groin for a right groin hematoma and an order to empty and monitor the drain every shift. On two separate observations, there was no EBP order, no signage, and no setup in place, even though the facility’s EBP policy requires use of gowns and gloves and posting of EBP signs for residents with indwelling medical devices, regardless of colonization status. The Infection Preventionist acknowledged that R96 should have had an EBP order due to the surgical drainage. A second deficiency was identified during a medication pass observation involving R89. An LPN prepared a 100 mg dose of magnesium oxide when only a 400 mg house stock tablet was available. The LPN cut the 400 mg tablet into four parts, handled the medication pieces with bare hands, and returned the remaining three-quarters of the tablet to the original stock bottle without performing hand hygiene at any point. The DON later stated that medications should not be touched with bare hands and that once a tablet is split, any unused portion should be discarded rather than returned to the original container for infection control purposes. The facility did not have a specific written policy on handling medications, but the stated standard practice was that medications should not be handled with bare hands for infection control reasons.
Failure to Maintain and Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information form posted at the front desk was updated each day, potentially affecting 92 residents receiving care. On 12/2/25 at 9:24 AM, surveyors observed that the posted daily nurse staffing form still showed the date 11/24/25. The receptionist stated she was responsible for updating the daily nursing posting when she arrived at work at 8:00 AM but reported that she became busy due to the holiday and forgot to update it. When informed of this observation at 1:28 PM the same day, the administrator acknowledged that the 24-hour nurse staffing form should be updated and posted on a daily basis and also stated that the facility did not have a policy on daily nurse staffing posting. The facility was unable to provide a policy related to this requirement. No additional resident-specific clinical information or medical histories were provided in the report beyond the statement that 92 residents were receiving care in the facility at the time.
Failure to Notify Responsible Party and Physician of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident's responsible party and physician when there was a significant change in condition, specifically related to weight loss and the identification of a new wound. Interviews and record reviews revealed that a resident with multiple diagnoses, including Parkinsonism, impaired mobility, and a high risk for pressure ulcers, developed a new wound prior to discharge. The wound was identified by a registered nurse, who covered it with a dressing but did not notify the physician or nurse practitioner. The wound care nurse was informed about the new wound only shortly before the resident was discharged, and by the time the nurse attempted to assess the wound, the resident had already left the facility. Additionally, the facility did not notify the resident's family or responsible party about the new wound or the resident's weight loss, despite facility policy requiring immediate notification of significant changes in a resident's condition. The director of nursing confirmed that the family was not informed of these changes prior to discharge. The facility's policies on change of condition and weight monitoring require prompt communication with the physician and family when significant changes occur, but these procedures were not followed in this instance.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations of unclean and damaged conditions in resident rooms and care areas. Six residents were directly affected by these deficiencies, including residents with complex medical histories such as dementia, Parkinson's disease, and heart failure. The surveyor observed significant dust, residue, and soiling on personal protective equipment bins, medical equipment, and various surfaces within resident rooms. Specific instances included a bladder scan machine left uncovered and soiled in a hallway, a resident's room with a missing drawer and broken handles on furniture, and another resident's oxygen machine covered in dust. Additionally, several rooms had unclean conditions such as stained pillowcases, dusty blinds, and soiled bed rails. The facility's Director of Nursing confirmed these observations and acknowledged that the rooms and equipment should have been maintained in a clean condition. The facility's policies on housekeeping and infection control were not adhered to, as evidenced by the persistent unclean conditions despite daily cleaning protocols. The Director of Nursing stated that housekeeping and maintenance staff are responsible for cleaning and maintaining resident rooms, yet the observed conditions indicated a failure to meet these standards. The facility's failure to ensure a clean and safe environment for residents was a clear deficiency in their care practices.
Inadequate Supervision During Smoking Leads to Resident Falls
Penalty
Summary
The facility failed to provide effective fall interventions and adequate supervision for a resident while smoking, leading to a deficiency. The resident, a male with multiple diagnoses including dysarthria, lack of coordination, abnormalities of gait and mobility, and a history of falling, was involved in two incidents where he fell while smoking. On one occasion, the resident fell out of his wheelchair while attempting to pick up a dropped cigar, resulting in his face landing on the concrete. The staff member present at the time, who was not trained to transfer residents or evaluate them after a fall, had to call for nursing personnel to assist the resident. The facility's policy requires that residents assessed as unsafe smokers receive supervision during smoking. However, the staff did not provide adequate supervision or assistance to the resident, who was known to have impaired cognition and required a wheelchair for mobility. The resident's smoking assessment indicated that he was not a safe smoker and required management and supervision. Despite this, the resident was not provided with the necessary assistance when he dropped his cigar, leading to falls. The facility's policy on fall occurrences also mandates that interventions be put in place and reevaluated as necessary, which was not effectively done in this case.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who was physically abusive towards a resident. The resident, who has moderate cognitive impairment and requires assistance with daily activities, reported being forcefully pushed and hit by the CNA while attempting to get up from a wheelchair. This incident was corroborated by an Activity Aide who witnessed the CNA pushing the resident roughly onto a toilet, causing the resident to scream and cry. The facility's response to the incident was inadequate. The Director of Nursing (DON) and other staff members failed to conduct a thorough investigation or document the incident properly. Despite being informed of the abuse allegation, the DON did not utilize available Spanish-speaking staff to communicate effectively with the resident, who primarily speaks Spanish. Additionally, the Social Services Director did not complete any assessments or provide documented emotional support to the resident following the incident. The facility's abuse policy mandates a timely and thorough investigation of abuse allegations, which was not adhered to in this case. The lack of documentation and follow-up assessments highlights a significant deficiency in the facility's handling of the situation. The resident's care plan was not updated to reflect the incident, and there was no evidence of measures taken to prevent further occurrences of abuse.
Failure to Conduct Timely Background Checks for Identified Offenders
Penalty
Summary
The facility failed to follow their identified offender policy by not complying with state regulations in performing criminal background checks within 24 hours of the admission of new residents and failed to schedule a fingerprint-based criminal history record inquiry within 72 hours of receiving the initial criminal background results for four residents. This failure has the potential to affect the safety and well-being of all 89 residents currently residing in the facility. The facility's census indicated a total of 89 residents, with five identified offenders currently residing there. Interviews with the Social Services Director and Social Services Designee revealed that identified offender reviews for new residents upon admission were delayed due to the lack of an admissions director. An audit was performed towards the end of the year to initiate these reviews. The criminal history information response process should be done within 24 hours of admission, and fingerprinting should be completed within 30 days if applicable. However, the facility did not adhere to these timelines for four of the five identified offenders reviewed. The admission records and criminal history inquiries for the four residents showed significant delays and incomplete processes. For instance, one resident's initial criminal background results were expired, necessitating a new search. Another resident had no fingerprint documentation, and their sex offender check was incomplete. Additionally, two residents had sex offender checks attempted with no results due to system issues, and no further attempts were made. The facility's failure to conduct timely and complete background checks and fingerprinting for identified offenders compromised the safety protocols intended to protect all residents.
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 1,452 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.
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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.
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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) |
|---|---|---|---|---|
| Dobson Plaza | 0.7 mi | ★★★★★ | 0 | 0 |
| Elevate Care Chicago North | 1 mi | ★★★★★ | 6 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 1 mi | ★★★★★ | 3 | 0 |
| Aliya Of Evanston | 1 mi | ★★★★★ | 6 | 0 |
| Clark Manor | 1 mi | ★★★★★ | 1 | 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.