Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MATHER EVANSTON, THE

EVANSTON, IL · 37 certified beds · Last Life Safety survey March 20, 2025

CMS Certification Number 146145 · first certified December 2010

Ownership

Operated by MATHER SENIOR LIVING COMMUNITIES · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

25
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
10
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within IL

25 citations — more than 74% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 8 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (February 2026 to May 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 25 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

This facility25IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility25
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
132023-0542024-0482025-03
Citations at each Life Safety survey
Survey dateCitations
May 5, 202313
April 4, 20244
March 20, 20258

Most-cited tags

Most-cited tags at this facility
K-05312K-09182E-00412K-03452K-09142K-03512K-03632K-09202
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0531Have elevators that firefighters can control in the event of a fire.22025-03-20
K-0918Have generator or other power source capable of supplying service within 10 seconds.22025-03-20
E-0041Implement emergency and standby power systems.22025-03-20
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22025-03-20
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.22025-03-20
K-0351Install an approved automatic sprinkler system.22025-03-20
K-0363Install corridor and hallway doors that block smoke.22024-04-04
K-0920Ensure proper usage of power strips and extension cords.22024-04-04

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 9
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Emergency Preparedness Deficiencies 4
  • Services Deficiencies 2
  • Other 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies9
Gas, Vacuum, and Electrical Systems Deficiencies6
Emergency Preparedness Deficiencies4
Services Deficiencies2
Miscellaneous Deficiencies2
Construction Deficiencies1
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 20, 2025 — 8 citations

Citations issued on March 20, 2025
TagWhat the surveyor checksStatus
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (April 18, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (April 17, 2025)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (April 4, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 23, 2025)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (April 2, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 11, 2025)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (April 17, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 18, 2025)

April 4, 2024 — 4 citations

Citations issued on April 4, 2024
TagWhat the surveyor checksStatus
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (May 3, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (May 3, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 3, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 3, 2024)

May 5, 2023 — 13 citations

Citations issued on May 5, 2023
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (June 23, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (June 23, 2023)
E-0041Implement emergency and standby power systems.Deficient, Provider has date of correction (June 23, 2023)
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (June 23, 2023)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (June 23, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (June 23, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 23, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (June 23, 2023)
K-0364Install properly constructed windows in hallway walls or doors.Deficient, Provider has date of correction (June 23, 2023)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (June 23, 2023)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (June 23, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (June 23, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (June 23, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.