Pearl of Evanston: Infection Control Gown Failures - IL
All three incidents happened on the same morning at The Pearl of Evanston. All three residents were on Enhanced Barrier Precautions, a targeted infection control protocol that requires staff to wear gloves and gowns during any high-contact care. Signs on the residents' doors said so.
Inspectors documented the failures on April 21, 2026, during a complaint inspection.
The first resident, an older man with intact cognition and an indwelling urinary catheter, had an Enhanced Barrier Precaution sign posted directly on his room door. At 9:50 a.m., inspectors observed a nursing assistant inside the room, no gown on, a Hoyer lift at the bedside and the resident already seated in a cardiac chair. She had just finished the transfer. "I didn't know I should have worn a gown to transfer R3 from bed to wheelchair," she told inspectors. Five minutes later, the floor's LPN confirmed the catheter was the reason for the precaution and that staff were supposed to wear both gloves and a gown for transfers.
The second resident was severely cognitively impaired. At 10:45 a.m., an LPN and a CNA were changing his wound dressing. Neither wore a gown. The nurse supervisor, interviewed five minutes later, said the resident was on Enhanced Barrier Precautions because of his wounds and that gowns were required for wound care. She did not dispute what inspectors had just watched.
The third resident had a mild cognitive impairment and a documented Extended-Spectrum Beta-Lactamase infection in his urine. ESBL is a type of bacterial resistance that makes common antibiotics ineffective and spreads through contact. At 10:58 a.m., a phlebotomy technician drew his blood wearing only gloves. "I had gloves, and nobody told me to wear a gown," the technician said at 11:00 a.m.
The facility's own Enhanced Barrier Precaution policy, revised as recently as January 14, 2026, lists transfers, wound care, and providing hygiene as examples of high-contact activities requiring gowns and gloves. The policy describes the protocol as designed to reduce transmission of Staphylococcus aureus and multidrug-resistant organisms. Three of the five residents reviewed for infection control compliance had care delivered in violation of that policy on a single morning.
The Director of Nursing, interviewed at 1:45 p.m. that same day, acknowledged the requirement. "Our staff is supposed to follow the EBP guidelines with high contact resident care activities," she said. Her response to what inspectors had found: "I am going to start an in-service to educate my staff."
What the inspection captured wasn't a single worker cutting a corner. It was a nursing assistant who didn't know the rule, a phlebotomy tech who said no one had told her, and two clinical staff who skipped the gown during wound care while a nurse supervisor stood close enough to observe and correct them. The precaution signs were on the doors. The policy had been updated three months earlier. The knowledge wasn't reaching the people doing the work.
The man with the catheter sat in his cardiac chair that morning, cognitively intact, aware of what was happening around him, while a staff member who had just moved his body with a mechanical lift explained to inspectors that she hadn't known what the sign on his door meant.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl of Evanston,the from 2026-04-24 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
PEARL OF EVANSTON,THE in EVANSTON, IL was cited for violations during a health inspection on April 24, 2026.
All three incidents happened on the same morning at The Pearl of Evanston.
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.