Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Dobson Plaza during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of falls was left unsupervised during breakfast, contrary to her care plan requiring substantial assistance. This led to her attempting to get out of bed, resulting in a fall and a fracture. The CNA assigned was unaware of the resident's fall risk and had not been informed of specific fall prevention measures.
The facility failed to follow its food storage and labeling policies, affecting all 77 residents receiving meals. Observations revealed unlabeled and expired food items in the freezer, fluctuating freezer temperatures, and improper storage of dented cans. Additionally, wilted lettuce was found in a refrigerator, and a food cart with unattended items was left on an elevator. The Dietary Manager confirmed these practices violated facility policies, posing potential contamination and safety risks.
A resident reported an incident of potential abuse involving a staff member wrenching their arm, which was not reported to the State Survey Agency within the required 24-hour period. The resident, who is cognitively intact and on anticoagulant medication, experienced a delay in the investigation due to miscommunication among facility staff. The facility's policies on immediate reporting of abuse were not adhered to, resulting in a deficiency.
A resident reported an incident where a staff member allegedly wrenched his arm, leading to a large bruise. Despite the facility's policy requiring immediate reporting and investigation of abuse, there was a delay in initiating an investigation. The resident's account varied, and there was a lack of communication among staff, with the regional director unaware of the allegation until informed by a surveyor.
A facility failed to create a comprehensive care plan for a resident at risk for abuse. The resident, who is legally blind and requires assistance for daily activities, reported an incident of potential abuse. Despite this, no abuse risk assessment or care plan was in place, contrary to facility policies. Staff interviews confirmed the lack of assessments upon admission and the absence of an abuse care plan for the resident.
Failure to Provide Supervision During Feeding Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance during feeding for a resident, leading to an accident. The resident, a female with a history of mild cognitive impairment, repeated falls, and dementia, was left unsupervised during breakfast. Despite having a care plan that required substantial assistance with eating, the resident was served breakfast in her room without the necessary supervision, resulting in her attempting to get out of bed and subsequently falling. The incident occurred when the resident's bed alarm was triggered, and a nurse found her sliding to a sitting position on the floor. The resident sustained a fracture to her right shin bone after grazing it against the bedside table. The Certified Nursing Assistant (CNA) assigned to the resident was unaware of the resident's fall risk status and had not been informed of any specific fall prevention interventions. The CNA had left the resident unsupervised to retrieve a shower chair, during which time the fall occurred. The facility's policies on fall precautions and comprehensive care planning were not adequately followed. The care plan required substantial assistance with eating, which was not provided, and the resident's fall risk was not communicated to the staff responsible for her care. The lack of supervision and failure to implement safety interventions, such as lowering the bed or using floor mats, contributed to the resident's fall and subsequent injury.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to its food storage and labeling policies, affecting all 77 residents who receive meals from the kitchen. During observations, surveyors noted several deficiencies, including unlabeled and improperly stored food items in the freezer and dry storage areas. Specifically, there were unlabeled bags of green beans, English muffins, bagels, and muffins in the freezer, along with expired items such as tortillas and hamburger buns. Additionally, the freezer's temperature was fluctuating, and a large tub of ice cream was found to be soft, indicating improper storage conditions. In the dry storage area, there were unlabeled bins of oatmeal and dry milk powder, and dented cans were stored with undented ones, contrary to the facility's policy. Further observations revealed wilted lettuce in a refrigerator and a food cart with unattended items, including a cup of coffee, juice, cornflakes, and a partially eaten pastry, left on an elevator. The Dietary Manager confirmed that these practices were against the facility's policies, which require proper labeling and storage of food items, rejection of expired or dented items, and maintaining appropriate storage conditions. The manager acknowledged the risks associated with these deficiencies, such as potential contamination and safety hazards for residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility staff failed to report an allegation of abuse to the State Survey Agency within 24 hours, as required. This deficiency involved a resident who reported that someone attempted to wrench his arm while he was trying to get to the toilet. The resident, who is cognitively intact with a BIMS score of 14/15, has several medical conditions including legal blindness, muscle weakness, and is on anticoagulant medication. The incident was initially noted in a physical therapy note, but the report was not made to the appropriate authorities in a timely manner. The resident, who requires varying levels of assistance for daily activities, reported the incident to the physical therapy manager, who documented the complaint but assumed it had already been reported by the nursing staff. The resident's account of the incident was inconsistent, with changes in the timeline of when the alleged abuse occurred. Despite the physical therapy manager's awareness of the potential abuse, the report was not escalated as required by the facility's policies. Interviews with facility staff revealed a lack of communication and misunderstanding regarding the reporting process. The regional director and abuse coordinator were not fully aware of the resident's allegations until informed by the surveyor. The facility's abuse and neglect policies require all employees to report any incident or suspicion of abuse immediately, but this protocol was not followed, leading to a delay in addressing the resident's complaint and initiating an investigation.
Failure to Timely Investigate Allegation of Abuse
Penalty
Summary
The facility failed to initiate a timely investigation into an allegation of abuse involving a resident, identified as R70, who reported that someone attempted to wrench his arm while he was trying to get to the toilet. R70, a cognitively intact resident with a BIMS score of 14/15, has multiple medical diagnoses including legal blindness, muscle weakness, and is on anticoagulant medication. The incident was first documented in a physical therapy note by the physical therapy manager, V11, on 5/27/2024, after R70 reported the incident. An x-ray was conducted on the same day, showing no acute skeletal injuries, but the facility did not immediately initiate an investigation. During an interview with the surveyor on 06/10/2024, R70 described the incident, identifying the staff member involved as V12, and showed a large bruise on his left upper arm. The resident's account of when the incident occurred varied, initially stating it happened in March or April, and later saying it occurred a week ago Sunday. The physical therapy manager, V11, confirmed that the incident was reported to him by another therapist, V29, and that he informed the floor nurse, V12, assuming the nurses were already aware. However, the regional director, V3, was unaware of the allegation until informed by the surveyor. The facility's abuse coordinator, V2, stated that the facility's policy requires immediate reporting and investigation of any suspected abuse. Despite this, there was a lack of communication and coordination among staff, as V2 was not aware of any communication between V11 and V12, and the director of nursing (DON) was unavailable to confirm if an investigation had been initiated. The facility's policies, revised in September 2016, mandate that all employees report any incident or suspicion of abuse, but the delay in initiating an investigation suggests a failure to adhere to these procedures.
Failure to Implement Abuse Care Plan for Vulnerable Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was at risk for abuse. The resident, who is legally blind and requires varying levels of assistance for daily activities, reported an incident where someone attempted to wrench his arm while he was trying to get to the toilet. Despite this report, the facility did not have an abuse risk assessment or care plan in place for the resident, which is a requirement according to their policies. Interviews with facility staff revealed that abuse risk assessments are not conducted upon admission, and there was no separate assessment for abuse risk in the resident's records. The social service consultant, who is responsible for updating care plans, was unaware of any abuse care plan or risk assessments for the resident. The facility's policies state that residents with increased vulnerability for abuse should be identified through assessments and have care plans developed to address these risks, but this was not done for the resident in question.
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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) |
|---|---|---|---|---|
| Buckingham Pavilion | 0.6 mi | ★★★★★ | 6 | 0 |
| Alpine Care Of Evanston | 0.7 mi | ★★★★★ | 11 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 0.7 mi | ★★★★★ | 3 | 0 |
| Elevate Care Chicago North | 0.7 mi | ★★★★★ | 6 | 0 |
| Clark Manor | 1.3 mi | ★★★★★ | 1 | 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.