Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aliya Of Highwood during CMS and state inspections, most recent first.
The facility failed to provide adequate ADL assistance, including incontinence and hygiene care, to multiple dependent residents. One resident with significant physical and cognitive impairments was found lying on a saturated incontinence pad wearing two fully saturated briefs, with a strong urine odor and a reddened, excoriated peri area and buttocks; despite a care plan requiring barrier cream after each incontinent episode, no skin protectant was applied. Another resident, dependent on staff and transferred with a full-body lift, remained in a reclined wheelchair position placing pressure on the coccyx for several hours and was later found in a saturated brief smelling of urine, with a 1-cm open coccygeal area with exposed granulation tissue and no dressing present, despite staff stating the resident was changed every two hours. A third resident with hemiplegia and chronic conditions, who required substantial assistance with personal hygiene, was observed with long fingernails and a large amount of dark debris under the nails, contrary to the facility’s nail care policy and the DON’s expectation that nails be kept clean.
A resident with hemiplegia, muscle weakness, and communication deficits, documented as 73 inches tall, was observed lying in a bed that did not accommodate his height, with bent knees and a foot extending off the wooden footboard. He reported that a longer bed would be more comfortable and demonstrated how his knees were forced upward when his feet were on the bed. The DON stated uncertainty about the availability of a longer bed, and the Administrator reported that staff were unaware of the resident’s desire for a longer bed and could not confirm whether anyone had noticed his feet hanging off the bed, despite a facility policy requiring evaluation and reasonable accommodation of individual needs and preferences.
A resident with left wrist and pelvic fractures returned from an orthopedic follow‑up visit with her cast removed and a wrist brace reportedly provided, but the after‑visit summary only documented an OT referral and did not mention the brace or revised instructions. An RN observed the resident’s swollen wrist without any splint or brace in place, and the ADON was initially unaware that a brace had been issued. No timely nursing documentation of the follow‑up findings or new orthopedic recommendations was entered into the EMR, and updated orders for use of a Velcro wrist brace and related care were not added until two days after the appointment.
Two residents with existing pressure injuries and identified risk did not receive ordered pressure ulcer care and preventive measures. One resident with severe cognitive impairment and multiple heel pressure ulcers was repeatedly observed sitting in a recliner with direct pressure on the coccyx and heels, without heel offloading or a pressure-reducing pad, despite orders and a care plan to offload heels with heel boots or pillows. Another resident with a large stage 3 sacral pressure injury and an unstageable left great toe wound, both with daily treatment orders, was found with no dressings on either wound during care, while heels rested directly on the bed. Staff acknowledged expectations that treatments protect pressure injuries, and facility policy referenced the need for consistent wound monitoring and documentation, but offloading and dressing application were not consistently implemented.
Two residents experienced deficiencies in catheter-related care when staff did not adequately respond to severe new groin pain after a catheter change for a cognitively intact resident with a neurogenic bladder, and did not secure or properly position another resident’s indwelling catheter and drainage bag. In the first case, the resident repeatedly reported intense burning and razor blade-like pain in the groin and scrotum after the catheter change, staff administered tramadol but did not document the pain in the EMR or notify the provider despite facility policies on pain management and change in condition. In the second case, a resident was observed lying on unsecured catheter tubing that was taut from the weight of the drainage system, and a CNA briefly raised the drainage bag above bladder level, allowing urine to flow back toward the catheter, contrary to the facility’s catheter care policy requiring securement with a leg strap or similar device.
The facility failed to manage pain appropriately for two residents with significant medical conditions and PRN orders for analgesics. One resident with hemiplegia and a reddened perineal area reported back and arm pain and exhibited clear pain behaviors during incontinence care, yet received no PRN acetaminophen that day. Another resident with a pelvic fracture, bladder cancer, urinary drainage bags, and a large sacral wound showed abdominal pain, tensing, moaning, and verbal pain responses during peri-care, wound care, and limb movement, but was not given ordered PRN acetaminophen or hydromorphone on that day. These events occurred despite a facility pain management policy that defines pain as what the resident reports and calls for effective recognition and management of pain.
A deficiency was identified when a physician-ordered OTC medication, dextromethorphan 15 mg for TBI-related mood instability, was not available for a resident and was inaccurately documented on the MAR. An RN could not locate the medication during a morning med pass despite it having been ordered from the pharmacy days earlier. The DON stated that the pharmacy does not supply this OTC drug and that the facility is responsible for providing it, and that the nurse who entered the order should have received and reported a pharmacy message declining delivery. The MAR showed some doses signed as given and others marked as not available, and the facility’s medication ordering policy did not address how to obtain OTC medications.
A resident was observed with lidocaine pain patches left on a bedside table and self-applying them to both knees, while an RN confirmed that staff hand the patches to the resident for self-application. The MAR contained orders for lidocaine 5% patches to be applied to each knee, signed out by nurses as administered, but there was no physician order or interdisciplinary team determination authorizing self-administration of these patches and no corresponding self-administration assessment in the record. This conflicted with facility policies requiring secure medication storage and formal orders and assessments before allowing self-administration.
Two residents did not receive the planned noon meal when staff ran out of turkey casserole due to heaping scoop portions that exceeded the documented 6 oz serving size. The cook and the administrator both plated meals at the steam table, and when the casserole was depleted, the cook substituted hot dogs with carrots for the last two plates instead of the scheduled entrée. One affected resident reported that a higher-level staff member later acknowledged the hot dog was given by accident; the resident stated he would have preferred the regular meal and was not informed of the shortage or offered an alternative choice. The administrator confirmed the resident was not told about the lack of turkey casserole and was not offered an item from the alternative menu, despite the facility’s menu specifying turkey casserole, chopped carrots, and bread pudding for that meal.
A resident did not receive food and supplements consistent with documented dietary preferences and orders. During a mealtime observation, the resident’s tray contained an uneaten turkey casserole, carrots, and a small cup of fluid, but no soup or health shake, despite the dietary sheet specifying a daily health shake, a serving of soup, and no casseroles. The resident reported that the wrong food was sent every day and that requested soup was not provided. An RN confirmed that no health shakes had been sent to the floor after checking multiple dietary carts, and the Dietary Manager acknowledged that soup was not available even though it was listed on the resident’s dietary sheet.
Staff failed to follow the facility’s transmission-based precautions policy for a resident on strict contact isolation for C. diff. A housekeeping staff member cleaned the resident’s room wearing only gloves and no gown, despite a contact isolation sign on the door. At the same time, a CNA assisted the resident and removed dirty laundry in a yellow cinch bag, not an isolation bag, and left the room without wearing any PPE. The ICP later confirmed that gloves and a gown were required upon entry to rooms of residents on contact isolation, and facility records and policy documented that such precautions, including in-room care to prevent cross contamination, were ordered for this resident.
Residents reported ongoing issues with access to properly sized incontinence supplies, often receiving incorrect sizes or insufficient quantities, leading to discomfort and undignified care. Staff confirmed supply restrictions and acknowledged problems with inventory management. Additionally, a resident with behavioral health needs repeatedly directed verbal abuse at others, with staff and other residents witnessing these incidents and facility leadership not consistently intervening. These failures resulted in a lack of dignity and respect for multiple residents.
Staff failed to follow Enhanced Barrier Precautions for two residents with chronic wounds, including not wearing required PPE such as gowns during high-contact care and not posting appropriate EBP signage. Both the DON and Infection Control Nurse confirmed the need for gloves and gowns for residents on EBP, and facility policy requires these precautions for high-risk care activities.
A facility failed to double lock controlled substances in a medication cart, leaving them unsecured during medication administration. An LPN left the cart unattended and out of sight while administering medications to residents, with the lockbox containing controlled substances unlocked. The DON confirmed the importance of double locking to prevent theft, as outlined in the facility's policy.
A facility failed to refer a resident with bipolar disorder for a Level II PASARR screening, despite a reasonable suspicion of mental illness. The resident, admitted in 2019, was on antipsychotic and antidepressant medications. The Social Services Director could not find documentation of the required screening or referral, and the facility's policy for completing PASARR screenings prior to admission was not followed.
A facility failed to assess and document treatment orders for a new wound on a resident with a history of venous stasis wounds and lymphedema. Despite the resident's report of a new sore, the nursing staff did not document the wound or obtain treatment orders promptly. The wound care nurse was unaware of the blister until it was brought to her attention, and the wound doctor was notified two days later. The facility's Skin Management policy was not followed, leading to a deficiency in care.
A resident with severe cognitive impairment and high fall risk was transported in a wheelchair without foot pedals by the Social Service Director, leading to a deficiency in safety measures. The resident's toes repeatedly hit the ground during transport, despite staff awareness of the need for foot pedals to prevent injury. A policy for safe wheelchair transport was requested but not provided.
A resident with severe cognitive impairment and multiple medical conditions received a water flush through a G-tube without prior verification of tube placement by a nurse. The facility's policy did not explicitly state the procedure for checking tube placement, contributing to the deficiency.
A facility failed to follow manufacturer instructions for an insulin pen, impacting a resident with type II diabetes. A nurse prepared the pen without attaching the needle during priming, contrary to guidelines, potentially affecting the insulin dose administered. The DON confirmed the correct procedure involves attaching the needle before priming to ensure accurate dosing.
A resident was repeatedly found without access to water, displaying signs of dehydration such as dry lips and mouth. Despite no fluid restrictions or swallowing issues, the facility staff failed to ensure water was within reach, contrary to the care plan and hydration policy.
A facility failed to provide wound treatment as ordered for a resident with a stage 4 pressure ulcer. The Wound Care Nurse/ADON found that the resident's dressing was not changed as scheduled, with the last change occurring four days prior, despite orders for every other day treatment. An LPN confirmed that wound care should follow the doctor's orders.
A facility failed to investigate an abuse allegation when a resident reported that his roommate used a racial slur against him. The incident was reported to a registered nurse and the police, and the accused resident was moved to a different room. However, the facility administrator did not conduct an investigation, contrary to the facility's abuse policy, which mandates prompt investigation of all abuse allegations.
A resident with multiple diagnoses refused medication administration, leading to a failure in protocol when the nurse left the medication at the bedside. Despite the resident's refusal, the Medication Administration Record was inaccurately signed as if the medication was given. The ADON acknowledged the error, noting that the facility's policy requires staff to ensure medication is taken, which was not adhered to in this instance.
The facility failed to provide necessary wound care for two residents with nonpressure wounds. One resident with necrotizing fasciitis had undressed wounds despite daily care orders, while another with Hidradenitis Suppurativa missed multiple wound care treatments. The facility lacked a policy for nonpressure wound care.
Failure to Provide Adequate ADL, Incontinence, and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), including incontinence and hygiene care, to residents who were dependent on staff. One resident with hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, and abnormal posture required substantial/maximal assistance with personal hygiene and was dependent on staff for toileting hygiene. This resident was found lying in bed on an incontinence pad with a large yellow wet area and a darker yellow ring, wearing two incontinence briefs that were completely saturated with urine and emitting a strong urine odor. When the CNA removed the briefs and provided incontinence care, the resident’s peri area and buttocks were reddened and excoriated, and the resident moaned and said “ouch” multiple times during cleansing. Despite a care plan directing staff to apply barrier cream after each incontinent episode for moisture-associated skin damage, no skin protectant was applied before a new brief was placed. Another resident, who was dependent on staff and used a reclining wheelchair and full-body mechanical lift, was observed sitting for hours in a reclined position that placed pressure directly on the coccyx, without engaging activity. When CNAs later transferred this resident to bed, the incontinent brief showed dark blue wetness indicator lines and was saturated with dark yellow urine, and the resident smelled of urine. Examination of the coccyx revealed a 1-centimeter open area with exposed granulation tissue, surrounding pallor, and mottled redness, with no dressing found in the bed or brief. A CNA stated that this resident is changed every two hours and is laid down after lunch, but also reported that the last incontinence change had occurred when the resident was gotten up at breakfast, indicating a gap of several hours without incontinence care. A third resident with hemiplegia, repeated falls, aphasia, and chronic kidney disease required substantial/maximal assistance with personal hygiene. This resident was observed with a splint on the left hand and long fingernails on the right hand, with a large amount of dark substance under the fingernails. When asked, the resident agreed to have the nails cleaned and cut. The care plan indicated the resident required assistance with daily care needs related to hemiplegia, and the facility’s nail care policy required removal of dirt from under fingernails and performance of nail care on shower days and as needed. The DON stated that residents’ hands should be washed before meals and that he would expect residents’ nails to be clean, but the resident’s observed nail condition showed that this assistance with hygiene had not been provided as required.
Failure to Provide Bed Accommodating Resident’s Height
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate an individual resident’s need for a bed suited to his height. The resident was admitted with diagnoses including hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia, and his record showed a height of 73 inches. During observation, he was seen lying in bed with the head of the bed slightly elevated, his knees bent, and his left foot extending off the wooden foot end of the bed. When asked about his comfort, he reported that he was 6 feet 2 inches tall and that a longer bed would be more comfortable. He demonstrated that when he placed his feet on the bed, his knees were forced upward, and there was only a small amount of mattress above his head. In interviews, the DON stated he was not sure if a longer bed was available for this resident. The Administrator later reported that staff did not know the resident wanted a longer bed and could not say whether any staff had noticed that his feet were hanging off the foot of the bed. These findings occurred despite the facility’s Accommodation of Needs policy, which states the facility will evaluate and make reasonable accommodations for each individual’s needs and preferences, except when health and safety would be at risk.
Failure to Timely Clarify and Implement Orthopedic Brace and Wrist Care Orders
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals occurred when the facility did not obtain or clarify new orthopedic recommendations following a resident’s follow‑up appointment and did not timely update the medical record. The resident had a history of fractures of the left hand, distal radius and ulna of the left wrist, and superior and inferior pubic ramus fractures of the left pelvis, with prior instructions to use a left wrist splint and a platform walker to avoid weight bearing through the left wrist. During a morning medication pass, an RN observed that the resident’s left arm cast had been removed after an orthopedic follow‑up visit and noted that the left wrist remained slightly swollen. The resident and her husband reported that a brace had been provided and that they were told it could be worn whenever the resident wanted, but at that time the resident was not wearing the brace and there was no documentation in the electronic medical record regarding new orthopedic instructions or the brace. The after‑visit summary for the follow‑up appointment documented only an occupational therapy referral and did not mention a brace or revised instructions for wrist support or weight bearing. The ADON initially stated he was unaware of any brace sent with the resident after the appointment, and by the end of that day there were still no nursing notes in the EMR describing the orthopedic follow‑up findings or any new recommendations. A late entry progress note later documented that the splint had been removed and an OT referral given, but the original lack of timely documentation and clarification meant that the resident’s care orders, including use of a Velcro wrist brace and clarification of weight‑bearing status, were not updated in the EMR until two days after the follow‑up visit.
Failure to Offload Heels and Maintain Ordered Dressings for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer care and preventive measures for two residents with existing pressure injuries and identified risk. For one resident with severe cognitive impairment and dependence for all footwear tasks, surveyors observed on multiple occasions that the resident was seated in a reclining chair with direct pressure on the coccyx and both heels resting on the leg rest, without heel offloading or a pressure-reducing pad in the chair. The wound nurse confirmed the resident had a Stage 4 pressure ulcer and an unstageable pressure ulcer on the left heel and two unstageable pressure ulcers on the right heel, and stated the resident should wear pressure-reducing heel boots in bed and in the chair. The LPN reported the pressure reduction boots were in the closet, and the physician’s orders and care plan both directed that the heels be offloaded with heel boot protectors or pillows. The facility’s skin management policy did not include guidance for offloading pressure ulcers. For a second resident admitted with multiple diagnoses and assessed as at risk for pressure injuries, orders were in place for daily wound treatments to a sacral wound and a left great toe wound. During incontinence care, surveyors observed a large sacral wound with a dark central area and red surrounding tissue, with no dressing in place; the CNA stated she did not know when the dressing came off. Later, the wound nurse assessed the resident, who exhibited pain responses during sacral wound care, and confirmed an unstageable wound on the left great toe, also without a dressing in place, while the resident’s heels were directly on the bed. Wound documentation showed a Stage 3 sacral pressure injury measuring 10 cm by 10 cm and an unstageable pressure injury on the left big toe. The DON stated that treatments to pressure injuries are intended to add protection and that he expects treatments to be in place, and the facility’s skin management policy emphasized the need for a system to assure consistent implementation of monitoring and documentation protocols.
Failure to Address Catheter-Related Pain and Maintain Proper Catheter Positioning
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess and respond to a resident’s significant increase in groin pain following a urinary catheter change, and failure to maintain proper positioning and securement of another resident’s indwelling urinary catheter and drainage bag. One resident, cognitively intact and with a history of neurogenic bladder requiring an indwelling catheter, reported severe burning and razor blade-like pain in the groin and scrotal area beginning after a catheter change. Over several days, the resident repeatedly stated that the pain was intense, interfered with eating, and that he felt no one was paying attention to it, although he acknowledged receiving pain medication that only partially helped. Nursing staff, including an RN, were aware of the resident’s ongoing groin pain and were administering tramadol, and the DON and ADON knew he was in pain and had an upcoming urology appointment. However, they were unsure whether the physician had been notified, and it was later confirmed that no one had contacted the physician about the new or increased pain following the catheter change. The resident’s EMR contained no documentation of his pain complaints despite staff awareness and administration of pain medication. The resident’s care plan for indwelling catheter use included monitoring for signs and symptoms of UTI and notifying the MD of abnormal findings, and the facility’s pain management policy defined pain as what the resident says it is and allowed for notifying the health care provider of new or changed pain, but these provisions were not followed in relation to his reported catheter-associated pain. A second resident with an indwelling urinary catheter was observed lying on their side with the catheter exiting through the back of an incontinent brief, unsecured, and with the drainage tubing suspended off the bed so that the weight of the tubing held the catheter taut. When staff repositioned the resident up in bed, the catheter stretched, and the tubing remained under the resident’s leg. A CNA then lifted the urinary collection bag above the level of the bladder, causing urine in the collection tubing to flow back toward the catheter. The CNA acknowledged the resident should not be lying on the catheter tubing and that the securing device had come loose, noting that the securing device is applied by a nurse. The facility’s indwelling catheter care policy required securing and anchoring the catheter with a leg strap or other device, which was not done in this instance.
Failure to Provide PRN Pain Management During Care and Wound Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate pain management for residents who required such services, specifically affecting two residents reviewed for pain management. One resident was admitted with hemiplegia, hemiparesis, muscle weakness, abnormal gait, cognitive communication deficit, dysphagia, and abnormal posture. His care plan, initiated in December and updated in January, included participation in a personal pain management program, education on pain management including non-pharmacological approaches, and pain management as needed. An order was in place for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain. On one observed day, this resident reported back pain and an inability to move his right arm while lying in bed. Shortly afterward, a CNA provided incontinence care and lifted the resident’s right arm to change his shirt, during which the resident hollered, moaned, and stated that his right arm hurt. The CNA apologized and continued care, removing the resident’s soiled incontinence brief. The resident’s perineal area was noted to be very reddened, and when the CNA wiped the area with a towel, the resident moaned, moved side to side, and complained that his perineal area hurt. The Medication Administration Record for that day shows the resident did not receive any pain medication, although he did receive pain medication the following day for pain rated 7 out of 10. The second resident involved was admitted with diagnoses including a right pubis fracture, malignant neoplasm of the bladder, major depressive disorder, right hip pain, anxiety disorder, and osteoarthritis. Orders were in place for acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain, and hydromorphone 0.5 ml by mouth every eight hours as needed for pain. During an observed peri-care episode, CNAs removed the resident’s incontinence brief and noted a moderate amount of blood, believed to be from the rectum. When asked about pain, the resident patted her abdomen. The resident had two urinary drainage bags from the back area and a large, uncovered sacral wound. During wound care by an LPN/Wound Care Nurse, the resident tensed and moaned, and when asked afterward if the sacral area hurt, she nodded yes. When her right lower extremity was lifted, she said “Ow.” The Medication Administration Record for the month shows she had received acetaminophen and hydromorphone on earlier dates for high pain scores but did not receive any pain medication on the day of the observed pain behaviors, despite the facility’s pain management policy emphasizing recognition, management, and monitoring of residents’ pain.
Failure to Provide and Accurately Document Ordered OTC Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered medication was available and accurately documented as administered for a resident. During a morning medication pass, an RN was unable to locate the ordered dextromethorphan tablets, which had been ordered from the pharmacy several days earlier. The DON later explained that dextromethorphan is an OTC medication that the facility, not the pharmacy, is responsible for providing, and that the floor nurse who entered the order should have received and reported a pharmacy message indicating the medication would not be delivered. The resident’s January MAR showed an order for dextromethorphan 15 mg at bedtime for 3 days for TBI-related mood instability, with doses signed out as given, and a second order for dextromethorphan 15 mg twice daily for the same indication, with only the first dose signed out as given and subsequent doses marked as not available. The facility’s medication ordering policy did not address procedures for obtaining OTC medications, and no additional pharmacy policies were provided.
Improper Storage and Unauthorized Self-Administration of Pain Patches
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling of medication storage and administration for one resident using lidocaine 5% pain patches. During observation, the resident was found lying in bed with medication patches on her bedside table, which she stated were for knee pain and that she would apply when ready. During the same interaction, she placed both patches below each knee herself and reported that she always applies and removes them on her own. A subsequent interview with an RN confirmed that nurses give the patches to the resident and that the resident applies them herself. Record review showed active MAR orders for lidocaine 5% external patches to be applied topically to the left and right knees for pain management, with nurses signing these medications as given. However, there was no physician order authorizing self-administration of the lidocaine patches and no corresponding self-administration assessment for these patches in the electronic medical record. The only self-administration assessment on file, dated several months earlier, pertained to a different medication. This practice conflicted with the facility’s own policies, which require medications to be stored securely and accessible only to authorized staff, and which state that self-administration must be determined by the interdisciplinary team and supported by a specific order after assessing the resident’s ability to self-administer.
Failure to Follow Planned Menu and Portion Sizes Resulting in Substitute Entrées Without Resident Choice
Penalty
Summary
The deficiency involves the facility’s failure to follow the planned noon meal menu and portion sizes, resulting in two residents not receiving the scheduled turkey casserole meal. During observation of the noon meal service, the cook used a white 6 oz scoop to plate turkey casserole and chopped carrots while staff verbally requested meal textures. The administrator went behind the steam table and also began plating, using heaping scoop portions that created a mound over the flat of the scoop. As the last room cart was being plated, the cook scraped the metal tray to fill the scoop and ran out of turkey casserole, despite believing the correct serving ladle was used. Staff informed the cook that two more plates were needed, and the cook plated hot dogs with carrots for those two meals instead of the planned entrée. The dietary manager later confirmed that the facility ran out of turkey casserole and that two residents did not receive the regular meal, stating that the scoop sizes had been too large and should have been flat. One of the affected residents reported receiving a tray with a hot dog, believing it was the normal meal being served, and stated that a female staff member with long black hair, described as someone higher up, later told him they had accidentally given him the hot dog. The resident said he would have preferred the regular meal and felt he should have been given a choice of an alternative and informed that the facility had run out of the planned meal. The administrator confirmed that this resident was not informed of the shortage of turkey casserole and was not offered a choice from the alternative menu. The facility’s diet spreadsheet menu documented the turkey casserole portion size as 6 oz, with 4 oz soft chopped carrots and bread pudding as part of the planned meal.
Failure to Honor Resident Dietary Preferences and Ordered Supplements
Penalty
Summary
The facility failed to provide a resident with food that accommodated documented preferences and ordered supplements. On 01/12/2026 at 1:02 PM, the resident was observed lying in bed with the head of the bed at a 20-degree angle and an over-bed table holding an uneaten turkey casserole, uneaten carrots, and one 120 milliliter cup of fluid, with no health shake and no soup present. At that time, the resident reported that every day the facility sent the wrong food, that the facility never served the food on the menu, that soup had been requested but not provided, and that the resident could not eat the food that was sent. At 1:10 PM, an RN stated that dietary usually sent health shakes on the cart with the milk and, after checking four dietary carts on different hallways, reported that the kitchen had not sent any health shakes to the floor. At 1:20 PM, the Dietary Manager reviewed the resident’s dietary sheet and stated that the facility did not have soup and that health shakes were on the carts with the milk. The resident’s dietary sheet dated 01/12/2026 documented ordered supplements and preferences including “HEALTH SHAKE – 1 each,” “SOUP – 1 serving,” and “NO CASSEROLES,” which did not match the meal and items actually provided to the resident at the time of observation. These observations, interviews, and record review show that the resident did not receive the ordered health shake and soup and was instead served a casserole contrary to the documented preference of no casseroles, demonstrating a failure to accommodate the resident’s food and drink preferences as specified in the dietary sheet.
Failure to Ensure Required PPE Use for Resident on Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of personal protective equipment (PPE) for a resident on contact isolation. On 1/12/26 at 12:51 PM, a housekeeping staff member (V17) was observed cleaning the room of resident R91, whose door displayed a sign indicating "Contact isolation." During this activity, V17 was only wearing gloves and was not wearing a gown as required by the facility’s transmission-based precautions policy for contact isolation. At the same time, a CNA (V19) was in the same room assisting R91 and removing the resident’s dirty laundry, which was placed in a yellow cinch bag rather than an isolation bag. The CNA carried the laundry from the resident’s room to the soiled utility room without wearing any PPE, including gloves or a gown. On 1/13/26 at 1:05 PM, the facility’s infection control preventionist nurse (V18) stated that staff should wear gloves and a gown upon entering the room of a resident on contact isolation. Facility records showed that R91 was on strict contact isolation precautions due to C. diff, with orders indicating that all needs were to be rendered in the room to prevent cross contamination. An isolation list provided by the facility documented that R91 was on contact isolation for C. diff with a start date of 1/10/26 and a potential stop date of 1/20/26. The facility’s transmission-based precautions policy dated 1/1/25 specified that for contact precautions, hand hygiene and gloves upon entry to the room were required, and a gown was required.
Failure to Ensure Resident Dignity and Adequate Incontinence Supply
Penalty
Summary
The facility failed to ensure residents' dignity and rights by not providing incontinence supplies in the correct sizes and quantities, as well as by not preventing undignified interactions between residents. Multiple residents without cognitive impairment reported ongoing issues with access to appropriately sized incontinence briefs and pull-ups, with some residents forced to use incorrect sizes or go without supplies for extended periods. Staff interviews confirmed that supply distribution was restricted, with diapers stored in locked areas and limited quantities provided per shift, leading to shortages. The central supply and administrative staff acknowledged ongoing problems with supply management, including attempts to control inventory due to concerns about hoarding, but residents continued to report unmet needs. Additionally, the facility failed to prevent or address undignified verbal interactions among residents. Several residents and staff described incidents where one resident, with a history of mental illness and behavioral symptoms, verbally harassed and insulted other residents, including making derogatory comments about their weight and threatening statements. These behaviors were witnessed by other residents and staff, and in some cases, were not reported to or addressed by facility leadership. The affected residents generally reported feeling safe, but the incidents were recurrent and known to staff. The facility's policies regarding resident rights and dignity were requested but not provided during the survey. The combination of inadequate supply management for incontinence products and insufficient intervention in resident-to-resident verbal abuse resulted in a failure to uphold residents' rights to dignity, self-determination, and respectful treatment.
Failure to Implement Enhanced Barrier Precautions and PPE Use for Residents with Chronic Wounds
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for two residents with chronic wounds. In one instance, a CNA provided morning care to a resident on EBP, including changing an incontinent brief, transferring the resident, and changing bed linens, while only wearing gloves and not a gown as required. The CNA acknowledged awareness of the EBP protocol and the need to wear both gown and gloves to prevent cross-contamination. The resident's care plan documented the need for EBP due to infection prevention standards. In another case, a resident with a surgical wound requiring daily dressing changes and recent antibiotic treatment did not have the required EBP signage or orange dot indicator outside the room. The DON confirmed the resident was on EBP and that the sign may have been removed during a room change or cleaning. Both the DON and Infection Control Nurse stated that staff should wear gloves and gowns when providing care to residents on EBP, and facility policy specifies the use of gown and gloves for high-contact care activities for residents at high risk of MDRO transmission.
Failure to Double Lock Controlled Substances in Medication Cart
Penalty
Summary
The facility failed to ensure that controlled substances were double locked in a medication cart, as required by regulations. During an observation of medication administration, it was noted that the staff member, identified as V5, did not lock the medication cart when entering residents' rooms to administer medications. This occurred on multiple occasions, specifically when V5 was administering medications to residents R16, R56, and R17. During these times, the medication cart was left unattended and out of V5's line of sight, with the controlled substance lockbox within the cart being unlocked and accessible without a key. The facility's Director of Nursing, identified as V2, acknowledged that the medications in the controlled substances box are prone to abuse and theft, emphasizing the importance of double locking these medications. The facility's Medication Administration policy, dated January 2023, explicitly states that the medication cart should never be left open and unattended. Despite this policy, the controlled substances for residents, including narcotic pain medications and anti-anxiety medications, were not secured as required, posing a risk of theft or misuse.
Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a resident with a reasonable suspicion of mental illness was referred for a Level II PASARR screening. The resident, who had been diagnosed with bipolar disorder and had a history of suicidal ideations, was admitted to the facility in 2019. Despite the initial screening indicating a reasonable suspicion of mental illness, the facility did not complete the necessary referral for a Level II PASARR screening. The resident's care plan included antipsychotic and antidepressant medications, and he exhibited mood problems related to his bipolar disorder. Interviews with facility staff revealed that the Social Services Director, who was not in her current role at the time of the resident's admission, was unable to find documentation of the Level II PASARR screening or any referral made to the appropriate agency. The facility's policy required the completion of Level I and II screenings prior to admission, but the documentation was missing. The Director of Nursing confirmed that she was not involved in the PASARR screenings, indicating a lack of clarity in the roles and responsibilities for ensuring compliance with PASARR requirements.
Failure to Assess and Document New Wound
Penalty
Summary
The facility failed to assess and document treatment orders for a new wound on a resident with a history of venous stasis wounds and lymphedema. The resident, who has moderate cognitive impairment, reported a new sore on his right leg, but the electronic wound round reports did not reflect any open or active wounds. Despite the resident's concerns about the new sore, the nursing staff did not document the wound or obtain treatment orders in a timely manner. The wound care nurse was unaware of the new blister until it was brought to her attention, and the wound doctor was not notified until two days after the wound was discovered. The Director of Nursing and a Registered Nurse acknowledged awareness of the blister but failed to document the new order or perform an assessment. The facility's Skin Management policy emphasizes the importance of consistent documentation and assessment, which was not adhered to in this case.
Failure to Safely Transport Resident in Wheelchair
Penalty
Summary
The facility failed to safely transport a resident in a wheelchair, leading to a deficiency in ensuring a hazard-free environment and adequate supervision to prevent accidents. On the specified date, a resident, identified as R83, was observed being pushed in a wheelchair by the Social Service Director (V6) without foot pedals attached. During the transport, R83, who was wearing running shoes, attempted to lift his feet but was unable to consistently keep his right foot off the ground, causing his toes to hit the floor multiple times. This incident occurred despite R83's known high fall risk and severe cognitive impairment, as documented in his facility assessment and admission evaluation. Interviews with staff, including a Registered Nurse (V7) and the Director of Nursing (V2), confirmed that R83 was at high risk for falls and required foot pedals on his wheelchair during transport to prevent injury. The staff acknowledged that the absence of foot pedals could lead to potential harm, as R83 had a tendency to put his feet down. Despite the facility's awareness of the resident's condition and needs, a policy for safely transporting a resident in a wheelchair was requested but not provided, indicating a lapse in procedural adherence and safety measures.
Failure to Verify G-Tube Placement Before Water Flush
Penalty
Summary
The facility failed to ensure the proper checking of a gastrostomy tube (G-tube) placement before administering water flushes for a resident with severe cognitive impairment and multiple medical conditions, including chronic respiratory failure, cerebral infarction, dysphagia, and the use of a tracheostomy tube. The resident's physician orders required a 200-milliliter water flush every four hours through the G-tube. However, during an observation, a registered nurse administered the water flush without verifying the tube's placement, which is a critical step to prevent potential complications such as aspiration. The Director of Nurses acknowledged that staff should verify the G-tube's placement before administering any substances, as failing to do so could result in the tube not being in the stomach, increasing the risk of aspiration. Although the facility's policy on enteral tube medication administration emphasizes safe and effective practices, it does not explicitly outline the procedure for checking tube placement. This oversight in practice and policy contributed to the deficiency identified during the survey.
Failure to Follow Insulin Pen Manufacturer Instructions
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for the use of an insulin pen, which was observed during the administration of insulin to a resident with type II diabetes. The resident had an active order for 5 units of rapid-acting insulin to be administered at meals, along with a sliding scale order for additional insulin based on blood sugar levels. On a specific occasion, a registered nurse prepared the insulin pen by dialing in and depressing 2 units of insulin twice without attaching the needle, contrary to the manufacturer's instructions. The nurse then attached the needle and selected 13 units of insulin for administration based on the resident's blood sugar reading. The manufacturer's instructions for the insulin pen specified that the needle should be attached before priming the pen, and the pen should be held vertically to expel air bubbles. The Director of Nursing confirmed that the purpose of priming the pen is to ensure the resident receives the full dose of insulin and that the needle should be attached prior to priming. The failure to follow these instructions could potentially result in the resident not receiving the correct dose of insulin.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as R56, who was observed on multiple occasions without access to water. On the first observation, R56 was found in bed with dry lips and no water available in the room. The resident expressed thirst and consumed an entire cup of water when it was eventually provided by a nurse. Subsequent observations revealed similar conditions, with no water within reach, despite the resident's evident signs of dehydration such as dry lips and mouth. R56's medical records indicated no fluid restrictions or swallowing issues, and the care plan emphasized the importance of keeping water within reach and monitoring for dehydration signs. Despite this, the facility staff failed to ensure water was accessible, as evidenced by the resident's repeated expressions of thirst and physical signs of dehydration. The facility's hydration policy mandates routine monitoring and provision of fluids, which was not adhered to in this case, leading to the deficiency.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound treatment as ordered for a resident with a pressure ulcer. On a specific date, the Wound Care Nurse/Assistant Director of Nursing (ADON) noted that the resident should have received wound care and a dressing change to her coccyx wound two days prior, as the treatment was ordered every other day. However, the dressing in place was dated four days earlier, indicating a lapse in care. A Licensed Practical Nurse confirmed that wound care and dressing changes are supposed to be conducted according to the doctor's orders. The resident's care plan indicated an active stage 4 pressure ulcer on the sacrum, with treatment orders for cleansing, medication, and dressing changes every other day and as needed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. On August 29, 2024, a resident reported to a registered nurse and the local police department that his roommate had used a racial slur against him. The police responded to the call, and the facility moved the accused resident to a different room. However, the facility administrator did not conduct an abuse investigation, as she did not consider the incident an abuse allegation. The facility's abuse policy requires prompt and aggressive investigation of all reports and allegations of abuse. Despite this policy, no investigation was conducted following the incident. Both residents involved were cognitively intact, as indicated by their Minimum Data Set assessments. The facility's failure to investigate the reported incident is a violation of its abuse policy and prevention program, which aims to ensure residents are free from abuse and mistreatment.
Failure in Medication Administration Protocol
Penalty
Summary
The facility failed to ensure proper medication administration for a resident diagnosed with delusional disorder, major depressive disorder, parkinsonism, cervical disc disorder, spinal stenosis, and a history of falling. On multiple occasions, the resident refused to take medications when offered by the nursing staff. The nurse initially attempted to administer the medication at 5:00 PM, but the resident was in the restroom and refused. A second attempt was made at 6:00 PM, which was also refused. At 8:30 PM, the resident took the medication cup from the nurse and placed it on the bedside table, instructing the nurse to leave it there. The Assistant Director of Nursing (ADON) witnessed this interaction but did not ensure the resident took the medication. The Medication Administration Record indicated that the medications were signed out as given, despite the resident not taking them in the presence of the nurse. The ADON confirmed that it was not acceptable to leave medications unattended, as it was unclear if the resident would take them. The facility's policy requires that staff verify medication administration by remaining with the resident to ensure the medication is swallowed. However, this protocol was not followed, and the resident's self-medication assessment was not completed, nor was there a doctor's order or care plan in place for self-administration.
Failure to Provide Necessary Wound Care
Penalty
Summary
The facility failed to provide necessary care and treatment to residents with nonpressure wounds, as evidenced by the cases of two residents. The first resident, R2, was admitted with infectious wounds on her buttocks and lower legs due to necrotizing fasciitis. Despite physician orders for daily wound care, observations revealed that R2's wounds were not dressed, and the resident reported that her dressings had not been changed for a couple of days. The wound nurse confirmed that wound care should be performed daily, and if unavailable, the floor nurse could also perform the treatments. The second resident, R3, had open wounds in the axilla and groin areas due to Hidradenitis Suppurativa. Physician orders required daily cleansing and application of wound care products, but the treatment administration record showed multiple days where no wound care was provided. The facility was unable to provide a policy on the care and treatment of nonpressure wounds when requested by the surveyors, indicating a lack of adherence to established care protocols.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,056 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Highwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Barr North Shore | 1.3 mi | ★★★★★ | 16 | 0 |
| Whitehall Of Deerfield | 3 mi | ★★★★★ | 2 | 0 |
| Northbrook Health And Rehab | 3.1 mi | ★★★★★ | 0 | 0 |
| Grove Of Northbrook,the | 3.5 mi | ★★★★★ | 1 | 0 |
| Elevate Care Northbrook | 3.5 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.