Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Highland Park Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and hemiplegia was found with a full-length body pillow tucked under the fitted sheet, positioned to restrict bed exit. Staff confirmed the pillow was used to prevent falls and keep the resident from getting up, and the DON acknowledged this could be considered a restraint, despite the care plan and MDS not indicating restraint use.
The facility failed to prevent cross-contamination by improperly handling contaminated linens and reusing disposable gowns. DS staff carried soiled bedding against their bodies and reused gowns, contrary to CDC guidelines. Interviews confirmed these practices, highlighting a lack of adherence to infection control protocols.
A resident with essential hypertension was repeatedly administered Metoprolol Succinate ER despite their pulse being below the prescribed threshold of 60, as per the physician's order. This occurred over several months, and an LPN confirmed the medication was given on multiple occasions when it should have been withheld.
A resident with COPD did not receive oxygen therapy as ordered, despite a physician's order for 2 liters per minute to maintain oxygen saturation above 88%. Observations showed the resident without oxygen on multiple occasions, and a nursing assistant confirmed the resident should have been wearing it.
A resident with a diagnosis of pain was administered Tylenol in doses exceeding the prescriber's parameters. The physician's order specified a maximum of 3 grams per day, but the resident received 3.9 grams daily. This issue was confirmed by the DON, who noted that the order had been in place and followed since its inception.
The facility failed to provide a clinical rationale for the continued use of PRN psychotropic medication and did not perform a dose reduction for two residents. One resident, with moderate cognitive impairment, was on antidepressants without a valid rationale for continued use. Another resident, with severe cognitive impairment, was prescribed PRN Ativan without accurate justification, as the physician incorrectly cited hospice care, which was not applicable.
A resident in the facility received an incorrect dosage of Ferrous Sulfate due to discrepancies between the physician's order, the pharmacy label, and the MAR. The resident was supposed to receive 810 mg, but due to a labeling error, only 594 mg was administered. This discrepancy was confirmed by an LPN and the DON.
Improper Use of Positioning Device as Restraint
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral infarction resulting in left-sided hemiplegia and hemiparesis, severe cognitive dysfunction (BIMS score 0/15), and full dependence on staff for activities of daily living was found to be restrained in bed. The resident was admitted to hospice care and required a wheelchair for mobility with staff assistance. The care plan indicated the use of pillows for injury prevention due to involuntary movements, but did not specify the use of restraints. Multiple observations revealed a full-length body pillow tucked under the fitted sheet on the resident's left side, positioned in a way that restricted the resident from getting out of bed. Staff interviews confirmed the pillow was consistently used to prevent the resident from falling out of bed and to keep the resident from getting up. The Director of Nursing acknowledged that the placement of the pillow under the fitted sheet and out of the resident's reach could be considered a restraint. The MDS assessment did not indicate the use of restraints for this resident.
Deficiencies in Linen Handling and Gown Use
Penalty
Summary
The facility failed to handle contaminated linens in a manner that prevented potential cross-contamination for all residents. Observations revealed that Domestic Service (DS) staff carried contaminated bedding against their bodies from resident rooms to the laundry room, contrary to the facility's policy and CDC guidelines, which require contaminated textiles to be placed in bags or appropriate containment to prevent leakage. Interviews with the DS staff and the Director of Nursing (DON) confirmed that the staff did not bag dirty linen unless it contained body fluids or was visibly soiled. Additionally, the facility did not adhere to CDC and NIOSH guidelines regarding the use of disposable gowns. Observations showed that DS staff reused disposable blue plastic gowns while handling soiled linens, despite the guidelines stating that disposable gowns should not be reused. Interviews confirmed that the staff were required to dispose of disposable gowns after each use, but instead, they reused them until they were worn out. This practice was confirmed by the DON and a Registered Nurse (RN), who stated that disposable gowns should be discarded or reusable gowns laundered after each use.
Failure to Withhold Medication as Ordered
Penalty
Summary
The facility failed to adhere to a physician's medication order for a resident diagnosed with essential hypertension. The resident was prescribed Metoprolol Succinate Extended Release, with specific instructions to withhold the medication if the resident's pulse was below 60. However, a review of the Medication Administration Record (MAR) revealed that the medication was administered on multiple occasions despite the resident's pulse being below the designated parameter. The deficiency was confirmed through an interview with an LPN, who acknowledged that the medication was given on several dates when the resident's pulse was below 60. This oversight occurred over several months, from May to August 2024, indicating a repeated failure to follow the prescribed medication guidelines for the resident, potentially compromising their care.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident with Chronic Obstructive Pulmonary Disorder (COPD) received oxygen therapy as ordered. The resident's Minimum Data Set (MDS) indicated a requirement for oxygen therapy, with a physician's order specifying oxygen at 2 liters per minute to maintain oxygen saturations above 88%. However, observations on multiple occasions revealed the resident was not wearing their oxygen as ordered. On one occasion, the resident was observed in the dining room without oxygen, and on another, they were being pushed to their room in a wheelchair without oxygen. An interview with a nursing assistant confirmed that the resident should have been wearing oxygen, but was not.
Excessive Dosage of Pain Medication Administered
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically in terms of dosage exceeding the prescriber's parameters. A review of the resident's Minimum Data Set (MDS) indicated a diagnosis of pain, for which the resident was receiving routine pain medication. The physician's orders specified Tylenol 8-Hour Arthritis Pain Tablet Extended Release 650 MG, with instructions to administer 2 tablets by mouth three times a day, not to exceed 3 grams per day. However, the total daily dose administered was 3.9 grams, surpassing the prescribed limit. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the order had been in place and administered since its start date.
Failure to Ensure Clinical Rationale for Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure a clinical rationale for the continued use of PRN psychotropic medication and did not complete a dose reduction for two residents. Resident 40, admitted with depression and restless leg syndrome, was found to have moderate cognitive impairment and was on antianxiety and antidepressant medications. Despite a pharmacist's recommendation for a gradual dose reduction of bupropion, the physician declined without providing a valid clinical rationale, citing depression as the reason, which was confirmed by an LPN as not valid. Resident 46, admitted with a history of stroke and anxiety, had severe cognitive impairment and was on antianxiety medication. The resident's care plan indicated that hospice services were offered but declined by the family. The resident was prescribed PRN Ativan for agitation, and the pharmacist recommended a clinical rationale for its continued use beyond 14 days. However, the physician inaccurately cited hospice as the rationale, which was confirmed by an LPN as incorrect since the resident was never on hospice.
Medication Labeling and Administration Discrepancy
Penalty
Summary
The facility failed to ensure that medications were labeled and administered according to the physician's orders and the Medication Administration Records (MAR) for a resident. Specifically, there was a discrepancy in the dosage of Ferrous Sulfate Oral Solution prescribed and what was actually administered. The Physician's Order Summary indicated that the resident was to receive 13.5 ml of a 300 mg/5 ml solution, equating to a dose of 810 mg. However, the pharmacy label on the medication bottle instructed a different dosage of 18.5 ml, which would provide 814 mg of medication. The MAR reflected the physician's order of 13.5 ml of a 300 mg/5 ml solution to be administered daily. An observation revealed that an LPN administered 13.5 ml of a solution with a concentration of 220 mg/5 ml, resulting in a dose of only 594 mg, which was 216 mg less than the ordered dose. Interviews with the LPN and the Director of Nursing confirmed the discrepancy between the medication label and the MAR order. This inconsistency in medication labeling and administration led to the deficiency identified during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 23 citations issued within 25 miles in the last 12 months — 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 Alliance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hemingford Care Center | 17.9 mi | ★★★★★ | 23 | 0 |
| Cascades At Skyview | 32.7 mi | ★★★★★ | 12 | 0 |
| Chimney Rock Villa | 33.3 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Highland Park Care Center.
100% money-back within 48 hours.
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.