Aliya of Evanston: Resident Left Without Nurse on Christmas - IL
The resident, identified in federal inspection records only as R3, told inspectors he usually got his scheduled morning medications somewhere between 8:00 and 9:00 AM. On December 25, 2025, he had his breakfast. Then he waited. No nurse came to the second floor. His medications didn't come either.
When he said something about it, a certified nursing assistant was rude to him.
"He didn't feel safe and felt abandoned in the facility on Christmas Day," inspectors wrote, summarizing what R3 told them directly during a visit to his room on December 31. He was sitting upright in his room when they arrived, six days after the incident, and he still remembered it clearly enough to walk them through the timeline.
R3 is described in the inspection report as a man admitted to Aliya of Evanston whose medical records list, among other conditions, cervical disc degeneration, mild intermittent asthma, type 2 diabetes, disorders of the urethra, acute kidney failure, hypertension, hyperlipidemia, dementia with behavioral disturbances, bipolar disorder with psychotic features, alcohol abuse, depression, and adult failure to thrive. His age is redacted in the publicly released document. He had been admitted to the facility before Christmas.
The federal inspection, conducted January 2, 2026, was triggered by a complaint. Inspectors reviewed three residents for compliance with resident rights protections. R3 was the only one among them whose rights were found to have been violated.
The specific violation cited was the facility's failure to follow its own Residents Rights Policy, which inspectors noted includes a provision stating that residents must not be abused or neglected and must feel safe in the facility. Inspectors rated the level of harm as minimal harm or potential for actual harm, a classification that sits below the most severe findings but still requires a formal plan of correction and public disclosure.
What R3 described was a morning of compounding failures. No nurse on his floor. Medications that should have arrived by 9:00 AM that never came. A staff member who, instead of acknowledging his concern, was rude to him for raising it. And then, apparently, nothing, at least not until "way after breakfast," in R3's own words.
The facility's response, as recorded in the inspection report, was a cascade of in-service trainings on customer service.
The Director of Nursing told inspectors on December 30 that she would be scheduling an in-service on customer service. The Staffing Director, who also works as a certified nursing assistant, told inspectors on December 31 that the facility had already conducted in-service training on customer service and respecting patient rights. The Admissions Director, also on December 31, confirmed there had been an in-service on customer service. The Administrator told inspectors that afternoon that she had disciplined a number of staff members for customer service failures and that some had been dismissed.
Four separate administrators, on back-to-back days, all describing the same corrective framework: customer service training.
What none of them described, at least not in the inspection record, was any accounting of why there was no nurse on the second floor on Christmas morning. Not how long R3 waited. Not what medications he missed, or what the clinical implications were for a man managing type 2 diabetes, acute kidney failure, and bipolar disorder with psychotic features without his scheduled morning doses. Not whether anyone had checked on him that day before he flagged the problem himself.
The inspection report does not say what time a nurse finally arrived on the second floor. It does not say whether R3 received his medications that day, or whether the delay had any medical consequence. Those details, if they were documented anywhere, did not make it into the publicly released findings. What made it in was R3's account, given six days later, still specific enough to include the time he expected his medications and the fact that the CNA's response to his complaint was rudeness rather than help.
Nursing homes are routinely short-staffed on major holidays. Christmas, in particular, is a day when call-outs increase, agency staff may be unavailable, and supervisory presence on individual floors can be inconsistent. None of that is unique to Aliya of Evanston. What is notable here is that a resident with serious cognitive and medical conditions, a man whose diagnosis list includes dementia with behavioral disturbances and bipolar disorder with psychotic features, spent Christmas morning alone on a floor without nursing coverage, missed his medications, tried to advocate for himself, got treated badly for doing so, and then waited.
He told inspectors he was worried. The word he used, according to the report, was "worried." A man with dementia, who had been admitted to this facility before the holiday, was worried on Christmas morning because he understood enough about his own care to know that something had gone wrong, and he had no way to fix it.
The facility's Residents Rights Policy, reviewed by inspectors as part of the complaint investigation, explicitly states that residents have the right to safety and must not be abused or neglected. The citation issued against Aliya of Evanston is grounded in that language. The argument inspectors are making, in the dry regulatory phrasing of a CMS-2567 form, is that what R3 experienced on December 25 was a failure to ensure he felt safe. Not a paperwork error. Not a documentation lapse. A failure to make a vulnerable man feel safe on Christmas.
The facility's formal response to the inspection, beyond what administrators told surveyors on December 30 and 31, is not included in the publicly released narrative. Whether the plan of correction addresses the staffing gap that left the second floor without a nurse, or focuses primarily on the customer service training already underway, is not reflected in the document.
What is reflected is this: R3 sat in his room on New Year's Eve and told a federal inspector that six days earlier, on Christmas morning, he had been scared. That he had not gotten his medications. That a staff member had been unkind to him when he said so. That he had felt, in his own word, abandoned.
He was still there when inspectors arrived. Still in the facility. Still waiting, in whatever sense a man with his diagnosis list waits, to see whether what happened on Christmas would happen again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aliya of Evanston from 2026-01-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ALIYA OF EVANSTON in EVANSTON, IL was cited for violations during a health inspection on January 2, 2026.
On December 25, 2025, he had his breakfast.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.