Highland Health Care Center: Elopement Safety Failure - IL
Immediate jeopardy is the most serious finding federal inspectors can make. It means the danger is present, it is serious, and it has not yet been fixed.
The inspection, completed September 4, 2025, followed a complaint. What inspectors found when they arrived was a facility that had not been consistently completing elopement assessments, had not been documenting wandering and exit-seeking behaviors in any systematic way, and had not been updating care plans to reflect those risks. At least three residents had been identified as at risk for elopement. The facility's own elopement book, a log meant to track exactly these concerns, had not been maintained the way the facility's own policy required.
Elopement, in nursing home terms, means a resident leaving the building without staff knowledge. For residents with dementia or other cognitive impairments, that can mean wandering into traffic, into extreme weather, or simply disappearing. The consequences can be fatal.
The facility scrambled to respond before inspectors left. On September 3, 2025, the day before the inspection formally closed, the administrator launched weekly monitoring of the three at-risk residents, convened a Quality Assurance and Performance Improvement meeting, and pushed emergency in-service training across nearly every department in the building. The list of staff who were interviewed or trained reads like a full organizational chart: the administrator, the director of nursing, the assistant director of nursing, the CNA supervisor, the infection control nurse, the wound care coordinator, the social services director, the activity director, the speech language pathologist, the occupational therapy assistant, the human resources coordinator, the food service director, the housekeeping supervisor, certified nursing assistants, licensed practical nurses, a laundry worker, a kitchen aide, an activity aide, and a non-certified nurse aide.
In other words, nearly every person working in that building had to be told, in the days after inspectors arrived, where the elopement book was kept and what to do if a resident tried to leave.
The administrator, identified in the inspection record as V1, told surveyors that all staff had been in-serviced on the wandering and elopement policy and on the location of the elopement book. For anyone who had not yet received that training, V1 said it would happen before the start of their next shift.
Surveyors reviewed medical records, including the record of a resident identified as R2, and examined the facility's elopement book to verify that the immediate jeopardy had been removed. They also reviewed records for additional sampled residents to confirm the facility was now following its own policy. Based on that review, inspectors accepted the facility's corrective plan and marked the immediate jeopardy as abated on September 3, 2025.
The corrective plan calls for weekly monitoring of the three at-risk residents for an unspecified period, with results reviewed at QAPI meetings led by the administrator for 12 weeks. The facility committed to additional education and corrective measures if compliance is not sustained.
What the inspection record does not say is how long the gaps in assessment and documentation had been going on before a complaint prompted inspectors to show up. It does not say whether any resident left the building during that period. It does not say what happened to R2, whose record was reviewed in enough detail to be specifically noted, or why that resident's file warranted closer examination than the others.
What it does say is that a nursing home responsible for residents who wander, residents who seek exits, residents who may not understand where they are or why they should stay, did not have the basic systems in place to track that risk. The elopement book existed. The policy existed. The at-risk residents existed. The documentation and the monitoring did not.
The facility's 12-week QAPI review process is now underway. Whether it holds is a question that will be answered in the months ahead, in the records of residents whose names do not appear in this inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Health Care Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
HIGHLAND HEALTH CARE CENTER in HIGHLAND, IL was cited for violations during a health inspection on September 4, 2025.
Immediate jeopardy is the most serious finding federal inspectors can make.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.