Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Highland Oaks during CMS and state inspections, most recent first.
The facility failed to properly label and store food, with refrigerators lacking internal thermometers and uncovered food items in the walk-in cooler. These actions were contrary to the facility's policies, potentially compromising food safety for all residents.
The facility failed to ensure proper infection control practices, particularly in the use of PPE in enhanced barrier precaution rooms. Staff did not wear gowns or gloves during high-contact activities for residents with specific precautions, and soiled linens were improperly handled, leading to cross-contamination risks.
A resident's controlled substance medication, tramadol, was diverted in an LTC facility. The facility received 120 tablets, dispensed in four punch cards, but the fourth card was unaccounted for. The DON and Administrator confirmed the missing card, suspecting theft, as only nurses have access to the double-locked medications. The facility's policy defines this as misappropriation of resident property.
A facility failed to prevent the diversion of controlled substances, specifically tramadol, for a resident. The facility received 120 tablets of tramadol, but one punch card was missing. The issue was discovered during an investigation into another resident's missing medications. Interviews revealed no process to prevent a nurse from taking both the narcotic punch card and count sheet, facilitating the diversion. The facility lacked policies to prevent or identify such thefts.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, affecting all residents. During a kitchen tour, it was observed that a small refrigerator and a stand-up refrigerator lacked internal thermometers, with staff relying on external digital readings for temperature logs. This practice was contrary to the facility's policy, which required internal thermometers to ensure food safety. Additionally, the Cooling Temperature Log for the walk-in cooler was not up-to-date, with the last entry recorded months prior, and leftover ham from a recent meal was not logged as required. This oversight in documentation and monitoring could compromise food safety and increase the risk of foodborne illness. Further observations revealed that food items in the walk-in cooler, such as tiramisu, salads, and individual servings of salad dressings, were left uncovered, contrary to the facility's policy that mandates food to be covered to prevent cross-contamination. The Dietary Manager acknowledged these lapses, noting that the uncovered food should have been covered and labeled according to the facility's policies. The facility's policies from 2014 clearly outlined procedures for labeling, covering, and cooling leftover food, which were not followed, leading to the identified deficiencies.
Inadequate Use of PPE and Infection Control Practices
Penalty
Summary
The facility failed to ensure staff adhered to proper infection prevention and control protocols, particularly in the use of personal protective equipment (PPE) in enhanced barrier precaution rooms. For Resident 19, who had a gastrostomy tube and was on enhanced barrier precautions, staff were observed not wearing gowns or gloves during high-contact activities such as transferring the resident. Additionally, a social services staff member was seen sitting on the resident's unmade bed without wearing PPE, which is against the facility's policy for enhanced barrier precautions. Resident 16, who had a wound on his right toe and was on enhanced barrier precautions, was also subject to improper infection control practices. A CNA entered the resident's room without performing hand hygiene or donning the required PPE, despite the signage indicating the need for gloves and a gown during high-contact care activities. The CNA was observed providing toileting care without a gown, contrary to the facility's infection prevention expectations. For Resident 14, the facility's infection control practices were again not followed. A CNA was observed handling soiled linens without gloves and placing them on the floor, which the Director of Nursing acknowledged as a cross-contamination risk. The facility's policy did not specify where dirty linens should be placed to prevent such risks, contributing to the deficiency in infection control practices.
Diversion of Resident's Controlled Substance Medication
Penalty
Summary
The facility failed to prevent the diversion of a resident's controlled substance medication, specifically tramadol, which is a schedule IV narcotic pain medication. The facility received 120 tablets of 50 mg tramadol on behalf of a resident, dispensed in four separate punch cards, each with its own count sheet. The first three punch cards were accounted for, with the doses being administered between 5/16/24 and 6/15/24. However, the fourth punch card from the delivery on 5/13/24 was not accounted for, and the next dose given to the resident was from a new delivery of tramadol. The Director of Nursing (V2) and the Administrator (V1) both confirmed that the facility could not locate the missing card of tramadol, and the only explanation provided was theft. The medications are considered the resident's property, and the facility's Abuse and Neglect Prevention Protocol Policy defines misappropriation of resident property as using a resident's possessions without authorization. The controlled substances are double locked, and only nurses on duty have access, indicating a breach in the facility's protocol for safeguarding resident property.
Failure to Prevent Diversion of Controlled Substances
Penalty
Summary
The facility failed to implement policies to identify and prevent the diversion of controlled substances, specifically tramadol, for one of the residents. The facility received 120 tablets of 50 mg tramadol for the resident, which were delivered in four separate punch cards, each with its own count sheet. The first three punch cards were accounted for, but the fourth card was missing. The issue was discovered during an investigation initiated after another resident's controlled substances were reported missing. The missing tramadol for the resident was not discovered until at least a month later. Interviews with facility staff revealed that there was no process in place to prevent a nurse from taking both the narcotic punch card and the count sheet, which facilitated the diversion of controlled substances. The facility's administrator and director of nursing were unaware of the method used for the theft, and the facility lacked policies and procedures to prevent or identify such thefts. The facility's Controlled Substances Accountability Policy, dated after the incident, indicated that safeguards should be in place to prevent loss or diversion, but these were not implemented at the time of the incident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 619 citations issued within 25 miles in the last 12 months — including the 11 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl Of Elgin, The | 0.6 mi | ★★★★★ | 1 | 0 |
| The Pearl Of Fox River Valley | 1.7 mi | ★★★★★ | 13 | 0 |
| River View Rehab Center | 1.9 mi | ★★★★★ | 28 | 0 |
| Avondale Estates Of Elgin | 2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Elgin | 2 mi | ★★★★★ | 2 | 0 |
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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.