Health inspection·March 20, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their care planning policies by not ensuring a residents baseline care plan included safety/fall interventions. This failure applies to one (R1) of four residents reviewed for accidents on the total sample of 20. Findings include: R1 is a [AGE] year-old female with a diagnoses history of Prosthetic Heart Valve, Chronic Diastolic Congestive Heart Failure, Presence of Artificial Hip Joint, Primary Osteoarthritis of Hip, Dizziness, and Lack of Coordination who was readmitted to the skilled nursing unit on 02/25/2025. On 03/17/25 at 10:57 AM R1 stated she fell a couple of weeks ago and fractured her pelvis. R1's current physician orders includes an active order effective 03/03/2025 for Fall Risk Assessment Weekly for four weeks every day shift every 7 day(s) for fall precautions management for 4 Weeks. R1's admission Baseline Care Plan assessment dated [DATE] documents her vision is impaired, cognitively impaired, uses a walker, has a history of falls, her last fall was 2 months prior to admission which resulted in a fractured pelvis, she receives psychotropic, diuretic, and anticoagulant medications, and it does not include fall interventions. R1's current care plan does not include falls interventions and documents she sometimes has pain or feels weak and might require extensive assistance to transfers. R1's fall risk assessments dated 02/25/2025, 03/10/2025, and 03/17/2025 document she is at high risk for falls, and her fall risk assessment dated [DATE] documents she is at moderate risk for falls. On 03/19/25 at 11:37 AM V2 (Assistant Director of Nursing/Registered Nurse) stated R1 was admitted to the facility from assisted living on 02/25/2025 and did have falls while in assisted living. On 03/19/2025 at 1:19 PM V8 (Certified Nursing Assistant) stated she's always assigned to R1 when she works, and she thinks R1 might be a fall risk. V8 stated usually R1 doesn't get up on her own without assistance but sometimes when she arrives to work in the morning R1 is already dressed and in her chair. V8 stated R1 walks sometimes but tires easily and has an unsteady gait. V8 stated R1 hunches over and doesn't stand up straight. V8 stated R1 mostly walks in her room and doesn't like coming out of her room. V8 stated she assumes R1 is a fall risk but was never actually informed that she was. V8 stated she is normally notified of residents being a fall risk when they come in to the unit. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 146145 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mather Evanston, The 425 Davis Street Evanston, IL 60201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)