Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Pearl Of Evanston,the during CMS and state inspections, most recent first.
Staff failed to follow the facility’s Enhanced Barrier Precaution (EBP) policy requiring gown and glove use during high-contact care for multiple residents on EBP. One resident with an indwelling urinary catheter was transferred with a mechanical lift by a staff member who did not wear a gown and stated they were unaware it was required. Another resident with wounds received a dressing change from an LPN and a CNA who did not wear gowns, despite the nurse supervisor acknowledging that gowns were required for wound care under EBP. A third resident on EBP for ESBL in urine had blood drawn by a phlebotomy tech who wore gloves but no gown and reported that no one had told them a gown was needed. The DON confirmed that staff were expected to follow EBP guidelines for high-contact activities such as transfers and wound care, as outlined in the facility’s EBP policy.
A resident experienced a decline in range of motion or mobility because the facility did not provide appropriate care to maintain or improve ROM, and there was no documented medical reason for the decline.
A resident with multiple medical conditions and a stage 3 sacral pressure ulcer did not receive daily wound care as ordered by the physician, with no documentation or evidence of treatment provided for two consecutive days. The wound care nurse confirmed the lack of documentation, and facility policy requiring both treatment and documentation was not followed.
The facility failed to investigate and report a potential abuse incident involving two residents who had a verbal altercation, during which a table was overturned. Despite the police being called, no internal investigation was conducted, and the facility's abuse prevention policy was not followed.
The facility failed to ensure all staff were trained on handling resident altercations, resulting in an incident where two residents were left alone during a dispute. A housekeeping aide, who had not received abuse training, left the scene to find help, leading to a flipped table. Interviews revealed inconsistent abuse training among staff, contrary to the facility's policy.
The facility failed to ensure controlled substances were kept in locked compartments, left medication carts unlocked during administration, did not store refrigerated medications properly, and failed to date ophthalmic medications upon opening.
A facility failed to ensure a resident with Dementia and Alzheimer's disease was treated with dignity and respect. A PTA repeatedly asked the resident to stand for exercises while standing behind him, despite his requests for her to stand in front so he could see her. The Acting Therapy Director confirmed that staff should stand in front of residents when communicating.
The facility failed to ensure that a resident's medications were not kept at the bedside without a physician's order and did not assess the resident for safe self-administration. Medications were found in the resident's bedside drawer without proper documentation or orders, and the facility did not follow its policies on medication administration and self-administration assessment.
The facility failed to obtain a hospice plan of care for a resident receiving hospice services. The hospice plan of care was missing from both the hospice binder and the electronic health records, despite facility procedures requiring its inclusion.
The facility failed to provide necessary services and treatment to maintain and prevent further decrease in range of motion for three residents, leading to unaddressed contractures and lack of appropriate devices such as hand rolls and carrot splints.
The facility failed to implement its safety smoking policy for a resident who smokes five times a day and uses a CPAP machine at night. The Social Service Director admitted that the smoking assessment and care plan were not completed until prompted by the surveyor, despite the facility's policy requiring these assessments upon admission.
The facility failed to implement enhanced barrier precautions for a resident requiring high contact care. An LPN administered medications and feeding via a gastrointestinal tube without donning a gown, and the resident's room lacked appropriate signage and accessible PPE. The Director of Nursing confirmed the resident should have been on the EBP list and that proper PPE should have been used.
Failure to Follow Enhanced Barrier Precaution Gown Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precaution (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. For one male resident with intact cognition and an indwelling urinary catheter, surveyors observed an EBP sign on the room door indicating that gloves and a gown were required for high-touch activities. Despite this, a staff member (V3) reported having just completed a mechanical lift transfer of the resident from bed to a cardiac chair without wearing a gown, stating they did not know a gown was required. An LPN (V10) confirmed that the resident was on EBP due to the indwelling urinary catheter and that staff were supposed to wear gloves and a gown during transfers. Another male resident with severely impaired cognition was on EBP due to wounds. Surveyors observed an LPN (V12) and a CNA (V13) performing a wound dressing change for this resident without wearing gowns, and the nurse supervisor (V14) confirmed that staff were supposed to wear gloves and a gown during wound care under EBP. A third male resident with mild cognitive impairment was on EBP due to ESBL in urine. During a blood draw for this resident, a phlebotomy technician (V15) wore gloves but no gown and later stated that nobody had informed them that a gown was required. The DON (V2) stated that staff were supposed to follow EBP guidelines for high-contact resident care activities. The facility’s written EBP policy, revised on 1/14/26, defined EBP as targeted gown and glove use during high-contact resident care activities to reduce transmission of MDROs and listed dressing, wound care, transfers, changing linen, and providing hygiene as examples of high-contact activities.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care was provided unless a decline was for a documented medical reason. This resulted in a resident experiencing a decline in ROM or mobility without evidence that the decline was medically unavoidable.
Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to follow physician orders for wound care for a male resident with multiple complex medical conditions, including a femur fracture, cognitive deficits, chronic kidney disease, and a stage 3 pressure ulcer on the sacrum. Physician orders specified that the sacral wound should be cleansed, treated with Medi-honey and calcium alginate, and covered with a dry dressing once daily. However, review of the treatment administration record for two consecutive days showed no documentation that the wound care was provided as ordered, and the wound care nurse confirmed there was no evidence that the treatment was completed on those dates. Facility policy requires that dressing changes be performed according to physician orders and that completion of the procedure be documented in the treatment record. The wound care nurse stated that documentation is completed after the treatment is rendered, but no such documentation was available for the dates in question. There was also no documentation that the resident refused care on those days. Subsequent wound assessment indicated deterioration of the pressure ulcer, with increased necrotic and devitalized tissue, moderate exudate, and odor present.
Failure to Investigate and Report Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate and report an altercation between two residents, R1 and R2, which was a potential case of abuse. R1, a cognitively intact male with Parkinson's disease and other conditions, and R2, a severely cognitively impaired male with epilepsy and Alzheimer's disease, were involved in a loud verbal altercation in the dining room. A housekeeping aide, V9, witnessed the incident and left the room to find nursing staff, during which time a heavy dining room table was overturned. The police were called, but no internal investigation was conducted by the facility's administration. The Director of Nursing, V1, and the Administrator, V14, both acknowledged that no investigation was initiated following the incident. V14, who is responsible for investigating abuse allegations, admitted to not interviewing the housekeeper or conducting a thorough investigation. The facility's policy on abuse prevention, which mandates prompt and aggressive investigation of all abuse allegations, was not followed. This lack of action and failure to adhere to the facility's abuse prevention program resulted in a deficiency in handling potential abuse situations.
Failure to Train Staff on Abuse Prevention Leads to Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse policy by not ensuring that all staff were trained and knowledgeable on how to handle resident-to-resident altercations. This deficiency was highlighted by an incident involving two residents, R1 and R2, who were left alone during an altercation. R1, a male with intact cognition, and R2, a male with severe cognitive impairment, engaged in a loud argument in the dining room. A housekeeping aide, V9, who was present, became nervous and left the residents unattended to find nursing staff, resulting in a flipped dining room table. The aide admitted to not receiving any abuse training since starting work five months prior. Interviews with other staff members, including licensed practical nurses and a housekeeping supervisor, revealed a lack of consistent abuse training. Some staff members had not received any abuse training since their employment began, while others relied on previous training from different roles. The Director of Nursing confirmed that all new staff should be trained on abuse prevention and response, but the facility's policy was not effectively implemented. The facility's abuse prevention program outlined the need for orientation and annual training, but this was not consistently followed, leading to the incident involving R1 and R2.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure controlled substances and narcotic medications were kept in locked compartments within the medication cart. During an observation, a nursing supervisor left two controlled substance medications on top of an unlocked medication cart and walked away, leaving the cart unattended for several minutes. Additionally, multiple instances were noted where the medication cart was left unlocked while the nurse administered medications to residents, compromising the security of the medications. The Director of Nursing acknowledged that the medication cart should always be locked when out of sight and that controlled substances should be stored in locked compartments within the cart. The facility also failed to store medications requiring refrigeration according to the manufacturer's recommendations. Controlled substances such as Hydromorphone, Lorazepam, and Morphine Sulfate, which require refrigeration, were found stored in the medication cart instead. The facility's policy mandates that such medications be kept in a locked refrigerator or a locked box within the refrigerator. Additionally, the temperature monitoring of the medication refrigerator was not consistently recorded, with several dates missing from the log. Furthermore, the facility did not date ophthalmic medications upon opening, as required by their policy. During medication preparation for a resident, two eye medications were found without the date of opening. The nurse confirmed that eye medications should be dated when opened. The Director of Nursing reiterated that all medications should be stored and dated according to the facility's policies and procedures, which were not followed in these instances.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect. On 5/28/24, a Physical Therapy Assistant (PTA) asked a resident to stand up for walking exercises while standing behind the resident's chair. The resident, who has Dementia, Alzheimer's disease, and a cognitive communication deficit, requested the PTA to stand in front of him so he could see her. Despite the resident's repeated requests, the PTA continued to ask the resident to stand and walk without moving to the front. The surveyor intervened and informed the PTA of the resident's request, to which the PTA acknowledged she should have stood in front of the resident when communicating with him. On 5/30/24, the Acting Therapy Director stated that their usual practice is to introduce themselves, stand in front of the resident with eye contact, and explain the procedure. The director was informed of the observation and concern. The facility's policy on Resident's rights, reviewed on 5/8/23, emphasizes that each resident has the right to be treated with dignity and respect, and all interactions should focus on maintaining and enhancing the resident's self-esteem and self-worth, incorporating their goals, preferences, and choices.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure that no medications were kept at a resident's bedside without a physician's order and did not assess the resident for safe medication self-administration. During an observation, a registered nurse (RN) mentioned that a resident had already taken his medications and kept them in his bedside drawer. The medications included Spiriva Handihaler, Budesonide-Formoterol Fumarate, Fluticasone-Salmeterol, Combivent Respimat, and Diclofenac Gel. However, the RN did not sign off on the medication administration, and some medications listed on the resident's medication administration record were missing from the bedside drawer. Additionally, there were medications found in the drawer that did not have a physician's order, such as Allergy relief and Emergen-C. The Director of Nursing (DON) confirmed that the facility does not allow residents to keep medications at their bedside without a physician's order and that an interdisciplinary team must evaluate the resident for safe self-administration of medications before allowing it. The resident in question was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Congestive Heart Failure, Age-related Nuclear Cataract Bilateral, and Osteoarthritis (OA). The active physician order sheet listed specific medications for these conditions, but there was no order for the resident to self-administer these medications or to keep them at the bedside. The facility's policy on self-administration of medication requires an interdisciplinary team to assess the resident's ability to safely self-administer medications and obtain a physician's order before allowing it. The policy also outlines specific criteria for determining if self-administration is clinically appropriate, including the resident's cognitive status, physical capacity, and ability to follow medication instructions. The facility's medication administration policy also states that medications should not be left at the bedside without a physician's order and that all medications must be administered by licensed personnel. The facility failed to follow these policies, resulting in a deficiency in medication safety for the resident involved.
Failure to Obtain Hospice Plan of Care
Penalty
Summary
The facility failed to obtain a copy of the hospice plan of care for one resident (R76) who was receiving hospice services. During a record review, it was found that R76's hospice binder did not contain the hospice plan of care coordinated with the facility. Additionally, R76's electronic health records were also missing the hospice plan of care. Interviews with the Licensed Practical Nurse (V17) and the Director of Social Services (V8) confirmed that the hospice plan of care should be included in the hospice binder or scanned into the electronic health records for accessibility by all staff. R76 was admitted with diagnoses including unspecified dementia and moderate protein-calorie malnutrition, and had an order for hospice services dated 02/13/2024. The facility's Hospice Services Agreement and Hospice Program procedures clearly state that the hospice plan of care should be provided to the nursing facility and included in the resident's records. However, the facility did not adhere to these procedures, resulting in the absence of the hospice plan of care in R76's records.
Failure to Maintain Range of Motion for Residents
Penalty
Summary
The facility failed to provide services and treatment to maintain and prevent further decrease in range of motion for three residents. One resident, who had been at the facility for a couple of weeks, was observed with a left-hand contracture and expressed concern about his nails digging into his skin. The Registered Nurse acknowledged that no device had been placed in the resident's hand to prevent further contracture and notified the Restorative Nurse. The Occupational Therapist later recommended a carrot splint for the resident's left hand, but this was only after the surveyor's observation and intervention. Another resident was observed lying in bed with right fingers touching the right palm without any hand roll or carrot splint. The Restorative Nurse confirmed that the resident should have had a hand roll or carrot splint and noted that the current restorative program did not include the right hand. The Director of Nursing stated that the resident was not initially eligible for a splint or hand roll but acknowledged that recent therapy recommendations included passive and active range of motion exercises for both upper and lower extremities. A third resident was observed with bilateral elbow and wrist flexion contractures without any hand rolls in place. The Restorative Nurse and other staff members confirmed that the resident should have had preventative measures such as hand rolls and elevation of the right hand to decrease swelling. The resident's care plan was updated only after the surveyor's intervention to include these measures. The Occupational Therapy recommendations had been made prior to the survey but were not implemented until the deficiency was noted.
Failure to Implement Safety Smoking Policy
Penalty
Summary
The facility failed to implement its safety smoking policy for a resident who is a smoker. The resident, who is alert, oriented, and ambulatory, was observed to have a CPAP machine at her bedside and reported smoking five times a day. Despite the facility's policy requiring smoking assessments upon admission, quarterly, and as needed, the Social Service Director admitted that the smoking assessment and care plan for this resident were not completed until prompted by the surveyor. The resident was admitted with diagnoses including obstructive sleep apnea, PTSD, and schizoaffective disorder, but her smoking assessment and care plan were only initiated after the surveyor's inquiry. The facility's policy on smoking residents, reviewed earlier in the year, mandates that residents be evaluated for their smoking habits upon admission and that any smoking-related privileges, restrictions, and concerns be noted on the care plan. However, the Social Service Director acknowledged that he had not completed the necessary assessments and care plans for the resident due to prioritizing other assessments and getting acclimated to the facility. This oversight resulted in a failure to adhere to the facility's established safety smoking practices, affecting the resident's care and safety.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) when providing high contact resident care for one resident (R97) out of a sample of 25 reviewed for infection control protocol. On 5/28/24, it was observed that R97's room did not have an EBP sign posted at the door, nor was there a commonly shared isolation cart outside the door or in the hallway accessible to staff. An LPN administered medications and bolus feeding via a gastrointestinal tube to R97 while wearing gloves but did not don a gown, which is required for high contact care activities under EBP guidelines. On 5/29/24, the Director of Nursing presented an updated list of residents on EBP, which did not include R97. The Director confirmed that R97 should have been on the list and that the LPN should have worn both gloves and a gown when administering medications and feeding via the gastrointestinal tube. R97 was admitted with diagnoses including Dysphagia oropharyngeal phase, Gastrostomy status, Cachexia, and Apraxia, and had an active physician order indicating the need for EBP due to the presence of a gastric tube. The facility's policy on EBP, reviewed on 10/14/22, specifies that gown and gloves should be used during high contact resident care activities, including device care or use such as feeding tubes, and that PPE should be made available and accessible.
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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) |
|---|---|---|---|---|
| Mather Evanston, The | 0.7 mi | ★★★★★ | 0 | 0 |
| Aliya Of Evanston | 0.9 mi | ★★★★★ | 6 | 0 |
| Three Crowns Park | 1.3 mi | ★★★★★ | 2 | 0 |
| Citadel Care Center-wilmette | 1.7 mi | ★★★★★ | 1 | 0 |
| Alpine Care Of Evanston | 1.9 mi | ★★★★★ | 11 | 0 |
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