Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 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.
Incomplete Water Management Program for Legionella Control: The DON and Maintenance Director presented a water management plan that included an inaccurate water system diagram and did not identify dead legs, pipe corrosion, or stagnant water. The facility had no history of testing water for pH, chlorine, disinfectant, or bacteria including Legionella, and its records showed water heaters did not exceed 140°F. The plan also lacked validation methods, actions for Legionnaires’ disease or respiratory symptoms in high-risk residents, and strategies for external and internal water system risks.
Failure to properly evaluate and treat a resident’s coffee burn injury. A resident with Parkinson’s disease and hand tremors sustained a burn to the thigh after spilling hot coffee at dinner. Nursing notes showed the MD was notified and gave orders for moisturizer and monitoring, but staff only applied house lotion based on shift report, with no treatment order or wound documentation in the TAR. The wound later became red, warm, painful, and blistered, and the MD stated she was not notified of that change.
Failure to notify the MD and prevent worsening pressure ulcers occurred for a resident with Parkinson's disease, dementia, severe cognitive impairment, and dependence on staff for ADLs. The resident was high risk for skin failure and had a care plan for weekly skin checks and CNA reporting of any skin breakdown, but the record showed an open buttock wound that later deteriorated with additional buttock pressure ulcers, including one not documented in the EMR. The MD was not notified when the wounds were identified, and the MD stated she was not informed until later.
Mechanical soft diet items were not served as ordered for a resident with dysphagia after CVA. The resident, who had a mech soft diet with nectar thick liquids and was at aspiration risk, was served tropical fruit salad with pineapple, stringy sugar snap peas with stalks, and a baked potato with skin, despite the menu spreadsheet and facility policy specifying no pineapple, well-cooked vegetables, and no potato skins. The resident could not chew the items and had occasional coughing and throat clearing while eating.
Food held on the steam table for residents on pureed diets was below required hot-holding temperatures. Pureed sweet and sour pork and pureed sugar snap peas measured 111.5°F and 122.5°F, respectively, while the Dietitian stated hot foods should be at least 135°F. The Cook said he blended the cooked items with a little hot water and thickener, placed them directly on the steam table, and did not reheat them; the facility recipes also required hot foods to be held at 135°F and, for the pureed peas, reheated to 165°F within 2 hours.
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.
Incomplete Water Management Program for Legionella Control
Penalty
Summary
The facility failed to develop and implement a comprehensive water management program to detect and control Legionella and other waterborne pathogens in its water system. During review of the Water Management Program, the Director of Nursing and Maintenance Director presented a 3-page document that included a water system diagram listing a drinking fountain, although the Maintenance Director stated the facility did not have a drinking fountain. The water system description did not identify areas of dead legs, pipe corrosion, or stagnant water. An additional undated policy titled Infectious Disease-Legionella stated water should be stored above 140°F to continuously kill Legionella bacteria, but the facility’s water heater monitoring records for 2024 and 2025 showed both water heaters did not ever exceed 140°F. The Maintenance Director stated the facility had never tested municipal water or facility water for pH, chlorine or other disinfectant, or bacteria including Legionella to validate the effectiveness of control measures. The facility’s plan identified drinking fountains, ice machines, kitchen appliances, sinks, tubs, and showers as areas with potential for bacterial growth, but it did not address how effectiveness would be validated through water testing. During infection control review, the DON reported an increase in the infection control rate to 6.18% for November 2025 due to pneumonia and respiratory infections, and stated none of the residents were tested or had sputum cultures to identify a common organism. The water management plan also did not include actions for a resident diagnosed with Legionnaires’ disease or for high-risk residents with respiratory symptoms after being in the facility for more than 10 days, and it lacked strategies for external and internal risk factors such as water supply disruption, municipal water changes, construction, biofilm, scale, sediment, water pressure changes, pH level, and inadequate disinfection.
Failure to Properly Evaluate and Treat a Burn Injury
Penalty
Summary
The facility failed to properly evaluate and treat a resident who sustained a burn injury from spilled coffee. The resident had Parkinson’s disease with hand tremors and was burned on the left thigh while drinking coffee at dinner. Nursing documentation showed the physician was notified, and the physician gave an order to apply moisturizer, watch for open areas, cover with gauze dressing if tender, and notify the provider if the condition worsened. A later nursing note documented that the resident’s left thigh was red, warm to touch, and had blistered, fluid-filled areas, and that the resident’s POA and physician were notified. The treatment was not carried out through a documented treatment order or treatment administration record. A nurse stated she applied the facility’s house-supplied lotion and passed the information along in shift report, but did not create a treatment order flowsheet for documentation. Another nurse stated he was told to apply lotion, used the regular facility lotion, and had no treatment order to follow or document skin monitoring. Review of the treatment record showed no treatment order and no documentation of the left thigh burn wound. The physician stated the resident had a mild second-degree burn based on the photo sent by the facility, that hot coffee cups are expected to have lids, and that the resident would have benefited from assistive devices for tremors; she also stated she was not notified of the later change in the wound being reddened, painful, warm, and blistered.
Failure to Notify Physician and Prevent Worsening Buttock Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with Parkinson's disease with dyskinesia and dementia who was assessed as having severe cognitive impairment and dependence on staff for toileting, showering, personal hygiene, and bed mobility. The resident's pressure ulcer care plan identified high risk for skin failure related to advanced age, limited mobility, incontinent episodes, a history of pressure wounds to the buttocks, and spending most daytime hours sitting in a recliner. The care plan also directed weekly skin inspections and CNA notification of any redness, blisters, bruising, discoloration, or other signs of skin breakdown during daily care. The resident's records showed a right buttock wound identified by the facility as an open area, and later documentation showed deterioration with an additional pressure ulcer on the right lower buttock. During observation, the resident had a foam dressing on the right buttock, no dressing on the left buttock, and then was observed with an open red pressure ulcer on the right upper buttock, a pink intact area on the right lower buttock, and a red pressure ulcer on the left buttock that was not documented in the EMR. The physician was not notified when the buttock wounds were identified, and the physician stated she was not notified until later and that she expected to be notified of a resident's change in condition such as a pressure ulcer. The facility's pressure ulcer policy stated that weekly evaluation would be documented and that the MD and POA would be notified.
Mechanical Soft Diet Not Followed
Penalty
Summary
The facility failed to provide a mechanical soft consistency diet in accordance with the menu spreadsheet and facility policy for a resident with dysphagia after a cerebral infarction. The resident had diagnoses including cerebral infarction due to embolism of the right middle cerebral artery, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, unspecified dementia, and dysarthria following cerebral infarction. The resident’s physician order summary listed a mechanical soft diet with nectar thick liquids, and the nutrition care plan identified aspiration risk due to difficulty swallowing post stroke and directed that the diet be served per MD order. During lunch meal service, the resident was served tropical fruit salad with pineapple and sugar snap peas that were about 2 inches long with some hard stalks, even though the menu spreadsheet for mechanical soft diets specified tropical fruit salad with no pineapple and 2 ounces of sugar snap peas. The resident did not eat either item and stated she was unable to chew them. The resident was also served a baked potato with skin during lunch, and was noted to have occasional coughing and throat clearing while eating. The facility’s menu for the dinner meal on the same day showed that mechanical soft residents should receive baked potato without skin, and the facility policy for mechanically altered nutrition therapy stated that pineapple should be avoided, vegetables should be well cooked and easily mashed with a fork, fibrous or non-tender vegetables should be avoided, and potato skins should be avoided.
Food Held Below Required Hot-Holding Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures at the steam table for pureed foods served to residents on pureed diets. On the lunch menu, sweet and sour pork saute and sugar snap peas were served, and at 12:15 PM the pureed sweet and sour pork measured 111.5 degrees Fahrenheit and the pureed snap peas measured 122.5 degrees Fahrenheit. The Director of Dietary stated that meal service had started at 12:00 PM, and the Cook stated that he had prepared the pureed items around 10:00 AM by blending the cooked pork and snap peas, adding a little hot water and thickener, and placing them directly on the steam table. The Cook stated that the hot water in the steam table may not have been hot enough to keep the pureed items warm, and he did not reheat the items. The Dietitian stated that foods should be at a minimum of 135 degrees Fahrenheit at the steam table and that the pureed recipes should be followed during preparation. The facility’s pureed pork recipe required hot foods held for later service to maintain an internal temperature of 135 degrees Fahrenheit, and the pureed sugar snap pea recipe required reheating to a minimum internal temperature of 165 degrees Fahrenheit within 2 hours, then holding hot foods at 135 degrees Fahrenheit. The facility diet order listing showed that three residents were on pureed diets.
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.
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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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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 | ★★★★★ | 0 | 0 |
| River View Rehab Center | 1.9 mi | ★★★★★ | 7 | 0 |
| Avondale Estates Of Elgin | 2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Elgin | 2 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.