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Inspection Reports for Highview In the Woodlands

IL, 61072

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Inspection Report Summary

The most recent inspection on October 6, 2025, identified several deficiencies related to emergency preparedness, resident assessments, service plan documentation, tuberculosis testing, incident reporting, and resident rights notifications. Earlier inspections were not provided for comparison, so it is unclear whether these issues represent new or ongoing challenges. The main themes of deficiencies involved compliance with emergency drills and resident orientation, timely incident reporting, and proper medical and service documentation. There were no complaint investigations or enforcement actions listed in the available reports. Without prior inspection data, no clear trend of improvement or decline can be determined.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

71% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

8 6 4 2 0
2025
High (Actual Harm) Moderate (Potential Harm)
State average

Inspection Report

Annual Inspection
Deficiencies: 6 Date: Oct 6, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations including disaster preparedness, incident and accident reporting, physician's assessment, service plan, tuberculin skin test procedures, and resident rights.
Findings
The facility was cited for multiple violations including failure to conduct required tornado drills, failure to orient residents to emergency plans within 10 days of arrival, failure to report incidents within 24 hours, lack of physician assessments prior to admission for some residents, service plans not developed or signed by a registered nurse, failure to complete required two-step TB testing, and failure to ensure resident rights by timely notifying providers of changes in resident condition.
Deficiencies (6)
Failure to conduct tornado drills on each shift during February and failure to orient residents to emergency and evacuation plans within 10 days of arrival.
Failure to report a serious incident or accident within 24 hours to the Department of Public Health.
Failure to complete a physician assessment within 120 days prior to admission for residents.
Failure to have a registered nurse develop and sign residents' service plans.
Failure to comply with Tuberculosis Code by not completing two-step TB testing for residents upon admission.
Failure to ensure resident rights by not timely notifying provider of resident's change in condition after a fall.
Report Facts
Incident reporting delay: 2 Number of residents reviewed for incident/accident reporting: 3 Number of residents reviewed for physician assessment: 3 Number of residents reviewed for service plans: 3 Number of residents reviewed for TB testing: 3
Employees mentioned
NameTitleContext
E1DirectorInterviewed regarding tornado drills and incident reporting
E5Nurse ManagerInterviewed regarding physician assessments, service plans, and TB testing
E3Licensed Practical Nurse (LPN)Provided information about resident pain and incident reporting
E4Licensed Practical Nurse (LPN)Reported notifying Nurse Practitioner about resident's condition and x-ray
Z1Nurse Practitioner (NP)Interviewed about notification timing and x-ray orders related to resident fall

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