Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mather Evanston, The during CMS and state inspections, most recent first.
The facility failed to appoint a full-time Director of Nursing (DON) for its skilled nursing unit, impacting all 22 residents. Despite efforts to recruit, the facility has been unable to hire a qualified candidate, and the Assistant Director of Nursing is not comfortable assuming the role. The staffing list confirmed the absence of a designated DON.
The facility failed to offer the pneumococcal booster vaccine to four residents, despite their last vaccinations being over five years ago. The Director of Nursing/Infection Preventionist confirmed that the facility did not conduct pneumonia vaccine clinics, unlike those for influenza and COVID. The affected residents had various medical conditions, increasing their vulnerability to pneumonia. The facility's policy required a booster dose for adults 65 years or older, which was not followed.
A facility failed to include necessary fall interventions in a resident's baseline care plan, despite the resident's high fall risk and history of falls. Staff interviews revealed inconsistencies in awareness and implementation of fall precautions, and observations showed the resident's bed was not in the lowest position, lacking necessary safety measures.
A resident with multiple health issues experienced three falls during transfers due to the facility's failure to implement and communicate effective fall interventions. Despite a recommendation for two-person assistance after a previous fall, a CNA was unaware and attempted a solo transfer, resulting in another fall. The facility's Fall Prevention Protocol was not adequately followed.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis, affecting all 22 residents within the skilled nursing unit. On March 17, 2025, the Assistant Director of Nursing (ADON) reported that the facility currently does not have a DON. The Administrator stated that the skilled nursing team has been actively recruiting for the position by placing ads and visiting schools but has been unsuccessful in hiring a qualified candidate. The applicants either lacked sufficient experience or did not remain in the position. The ADON expressed discomfort with assuming the role of DON. The facility's staffing list provided during the survey confirmed the absence of a designated DON.
Failure to Offer Pneumococcal Booster Vaccine
Penalty
Summary
The facility failed to ensure that all residents were offered the pneumococcal booster vaccine, affecting four residents out of a sample of twenty. The Director of Nursing/Infection Preventionist (V2) acknowledged that residents should receive the pneumococcal vaccination booster every five years. However, the facility's practice was to check for historical vaccination records upon admission and only order the vaccine if there was no prior history. The facility did not offer a vaccination clinic for the pneumonia vaccine, unlike the influenza and COVID vaccines, which were offered almost twice a year. The vaccination history revealed that four residents had not been offered a pneumococcal booster shot despite having received their last vaccination more than five years ago. These residents had various medical conditions, including COPD, CVD, dementia, and heart failure, which could increase their vulnerability to pneumonia. The facility's policy on immunization, revised in May 2024, stated that for adults aged 65 years or older, a dose of PCV20 should be administered at least five years after the last dose of PPSV23, using shared clinical decision-making. This policy was not adhered to, leading to the deficiency.
Failure to Implement Fall Interventions in Resident's Care Plan
Penalty
Summary
The facility failed to follow their care planning policies by not ensuring a resident's baseline care plan included safety and fall interventions. This deficiency was identified for a female resident with a history of falls, impaired vision, cognitive impairment, and other medical conditions such as prosthetic heart valve and chronic diastolic congestive heart failure. Despite being at high risk for falls, as documented in multiple fall risk assessments, the resident's baseline care plan did not include necessary fall interventions. The resident had a history of falls, including a recent fall that resulted in a fractured pelvis, yet her care plan lacked specific interventions to mitigate fall risks. Interviews with staff revealed inconsistencies in their awareness and implementation of fall precautions for the resident. Some staff members assumed the resident was a fall risk but were not formally informed, while others used their judgment to implement certain precautions like using a gait belt and checking on the resident regularly. Observations showed that the resident's bed was not in the lowest position, and there were no mats on the floor, contrary to the stated needs for fall interventions. The Assistant Director of Nursing acknowledged the need for specific fall interventions, but the baseline care plan did not reflect these measures, leading to a deficiency in providing adequate care for the resident's safety needs.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to ensure effective fall interventions were in place and followed, resulting in multiple falls for a resident. The resident, a female with multiple diagnoses including congestive heart failure, respiratory failure, Parkinson's disease, dementia, and lack of coordination, experienced three falls during transfers on 11/26/2024, 1/15/2025, and 2/16/2025. Each fall occurred while the resident was being transferred by a single Certified Nursing Assistant (CNA), despite a recommendation for two-person assistance after the second fall. The deficiency was highlighted by the incident on 2/16/2025, where the CNA was unaware of the two-person assistance requirement and attempted to transfer the resident alone, resulting in another fall. The Director of Nursing confirmed that the recommendation for two-person assistance was made after the fall on 1/15/2025, but it was not effectively communicated to all staff. The facility's Fall Prevention Protocol requires a review of the resident's care plan and consideration of new interventions after a fall, which was not adequately implemented 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 1,453 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) |
|---|---|---|---|---|
| Aliya Of Evanston | 0.6 mi | ★★★★★ | 6 | 0 |
| Pearl Of Evanston,the | 0.7 mi | ★★★★★ | 5 | 0 |
| Alpine Care Of Evanston | 1.5 mi | ★★★★★ | 11 | 0 |
| Three Crowns Park | 1.9 mi | ★★★★★ | 2 | 0 |
| Lakefront Nursing & Rehab Ctr | 1.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mather Evanston, The.
100% money-back within 48 hours.
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.