Cycle 1
Health 2025-08-07 · Fire 2024-06-13
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Evanston, IL
Dobson Plaza
4-star overall rating with 5-star inspections with $19,383 in total fines
120 Dodge Avenue, Evanston, IL
(847) 869-7744
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-02-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
28%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,230
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9937
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.29
Baseline 21.27% · Performance 18.98% · Measure score 5.29 · Achievement 5.29 · Improvement 4.91
Healthcare-associated infections
0
Baseline 8.69% · Performance 8.61% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 27.78% · Performance 23.73% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.03
Baseline 2.20 hours · Performance 2.75 hours · Measure score 1.03 · Achievement 0 · Improvement 1.03
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.2% |
10.72%
2.5 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 1.2% · Lower 95% interval 5.31% |
| Discharge to community | 42.55% |
50.57%
8 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 32.56% · Lower 95% interval 28.93% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 38.89% |
53.69%
14.8 pts worse
|
Numerator 14 · Denominator 36 |
| Discharge mobility score | 47.22% |
50.94%
3.7 pts worse
|
Numerator 17 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 46 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.61% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 12.77% · Lower 95% interval 4.9% |
| Staff COVID-19 vaccination coverage | 3.03% |
8.2%
5.2 pts worse
|
Numerator 4 · Denominator 132 |
| Staff flu vaccination coverage | 33.97% |
42%
8 pts worse
|
Numerator 53 · Denominator 156 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 12 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 22 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
89.6%
5.5 pts better
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 81.9% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.9% |
91.6%
0.3 pts better
|
95.5%
3.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 1.2% · Q4 1.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 82.6% |
50.3%
32.3 pts worse
|
11.4%
71.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 82.9% · Q3 79.2% · Q4 85.5% · 4Q avg 82.6% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.5%
0.5 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 7.0% · Q3 10.3% · Q4 4.5% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
18.5%
1.7 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 13.9% · Q3 16.9% · Q4 20.3% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.9% |
22.8%
3.1 pts worse
|
16.7%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 21.3% · Q3 29.8% · Q4 35.0% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.8% |
17.2%
8.4 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 15.7% · Q3 10.1% · Q4 4.0% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
15.0%
9.4 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 3.1% · Q3 3.2% · Q4 3.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.1%
About the same
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.8% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.7% |
1.7%
7 pts worse
|
1.7%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.4% · Q3 9.0% · Q4 6.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.9% |
21.3%
16.4 pts better
|
19.8%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.9% · Q3 1.2% · Q4 4.9% · 4Q avg 4.9% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.2%
1.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.1% · Q3 3.6% · Q4 1.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
68.8%
22 pts better
|
81.7%
9.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q3 77.3% · Q4 87.5% · 4Q avg 90.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
14.0%
1.8 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.8% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.4% |
2.3%
8.1 pts worse
|
1.6%
8.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
63.0%
13 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
26.2%
12.3 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 15.4% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2023-08-04
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-04 · Fire 2022-07-21
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-06-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-06-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-19
E · Potential for more than minimal harm
2023-08-04
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-04
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
C · Minimal harm
2023-08-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-05
G · Actual harm
2023-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-26
Penalties and ownership
What sits behind the stars
$19,383
2023-05-02
Fine
Fine · fine $19,383
Fine
Ownership
Kohn, Charlotte
Operational/Managerial Control · Individual
Vexelman, Mark
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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3-star overall rating with 4-star inspections with 9 recent health deficiencies
#2
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#3
Westwood Vlge Nrsg And Rhb Ctr
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2-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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