Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Barr North Shore during CMS and state inspections, most recent first.
A resident with a history of falls, lack of coordination, and abnormal gait did not have floor mats at the bedside as required by their care plan. Despite a recent unwitnessed fall, observations confirmed the absence of this intervention, and staff acknowledged that care plan interventions should be in place.
A resident with a history of hip replacement and infection suffered an intertrochanteric fracture after a CNA reportedly handled her roughly during a diaper change, despite her refusal. The incident was corroborated by the resident's roommate and medical records, which highlighted the need for gentle handling due to the resident's impaired mobility and pain. Previous concerns about CNA roughness during night shifts were noted in the facility's resident council minutes.
The facility failed to store liquid lorazepam according to the manufacturer's guidelines, as it was found in medication carts instead of being refrigerated. This affected four residents, with LPNs and an RN acknowledging the oversight. The facility's policy requires medications to be stored per manufacturer's instructions, which was not followed in this case.
The facility failed to provide comfortable medical equipment for two residents. One resident's wheelchair was uncomfortable, and despite complaints, no action was taken due to a lack of communication among staff. Another resident's bed was malfunctioning, causing discomfort, but the issue was not reported to maintenance. Both cases highlight a breakdown in communication and reporting processes within the facility.
A resident requiring ongoing eye injections did not have an ophthalmologist appointment scheduled in a timely manner, despite a physician's order. The resident expressed frustration over the lack of follow-through, and the facility's ward clerk admitted the task was delayed. The ophthalmologist's office confirmed no contact from the facility, and the assistant administrator acknowledged the expectation for prompt scheduling was not met.
A resident with right-sided paralysis and chronic renal disease was unsafely transferred by two CNAs using a gait belt and manual lifting, contrary to the care plan that required a mechanical aid. The resident was unable to bear weight or pivot, highlighting a failure to ensure safe transfer practices.
A resident with a history of weight loss and multiple diagnoses, including moderate protein calorie malnutrition, did not receive the ordered fortified pudding with her meals. Despite a significant weight loss over several months, the resident's lunch tray lacked the prescribed supplement. The dietitian noted the resident's tendency to sleep during meals, which may have contributed to her weight loss, and the facility's policy did not address insidious weight loss.
A resident with a history of multiple health issues, including rheumatoid arthritis and dementia, experienced significant pain during incontinence care. Despite expressing severe pain, the nursing staff failed to conduct a comprehensive pain assessment before administering pain medication. The facility's policy requires thorough pain evaluations, which were not followed in this case.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peritoneal dialysis catheter upon admission. The resident was not identified for EBP, and staff were observed providing care without appropriate PPE. Interviews revealed that the Infection Control Preventionist and a Registered Nurse acknowledged the oversight, as the facility's policy requires EBP for residents with indwelling medical devices.
A resident with a suspected stress fracture did not receive ongoing assessments, leading to a delay in medical intervention. Despite an x-ray indicating a possible fracture, the resident's condition was not documented or assessed from 7/4 to 7/7, resulting in hospitalization for a femoral neck fracture and deep venous thrombosis. Staff interviews revealed a lack of communication and adherence to facility policies regarding changes in resident condition.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident, who was at high risk for falls due to lack of coordination and abnormal gait, did not have required fall prevention interventions in place. The resident's care plan, last reviewed on 5/19/25, specified that floor mats should be provided at the bedside as a fall intervention. However, during observations on 6/11/25, no floor mats were present in the resident's room while the resident was in bed. The resident had previously experienced an unwitnessed fall on 5/29/25, as documented in the progress notes and incident report. Staff interviews confirmed that fall interventions are determined after an incident and should be implemented as listed in the care plan, but the required intervention was not in place at the time of observation.
Resident Injury Due to Rough Handling by CNA
Penalty
Summary
The facility failed to ensure a resident was repositioned safely, resulting in a significant injury. A resident, who had a history of hip replacement and was recovering from a hip joint infection, reported that a Certified Nursing Assistant (CNA) was rough while attempting to change her, despite her refusal. The resident heard a pop in her hip and subsequently experienced pain, which led to a diagnosis of an intertrochanteric fracture requiring surgery. The resident's roommate corroborated the account, stating that the resident was upset and in pain after being moved by the CNA. The resident's medical records indicated she was dependent on staff for all activities of daily living and was incontinent, requiring maximum staff assistance. The facility's care plan for the resident emphasized the need for gentle handling due to her impaired mobility and pain. Despite this, the CNA reportedly attempted to change the resident multiple times against her wishes, leading to the injury. The facility's resident council minutes also noted previous concerns about the roughness of CNAs during the night shift, suggesting a pattern of behavior that may have contributed to the incident.
Improper Storage of Lorazepam
Penalty
Summary
The facility failed to store medications according to the manufacturer's guidelines for four residents. During an inspection, it was observed that liquid lorazepam, which requires refrigeration, was stored in the locked narcotic boxes of medication carts on both the first and second floors. Specifically, for residents R9, R12, R123, and R132, the lorazepam was not refrigerated as required. The medication for these residents was found either unopened or partially used, with dates indicating they had been stored improperly for several weeks. Licensed Practical Nurses (LPNs) V10 and V11, as well as Registered Nurse (RN) V15, confirmed that the lorazepam should have been refrigerated but had been stored in the medication carts instead. The facility's policy on medication storage, which mandates adherence to the manufacturer's recommendations, was not followed. The manufacturer's guide for lorazepam clearly states that it should be stored at a cold temperature, between 36 to 46 degrees Fahrenheit, which was not adhered to in these instances.
Failure to Provide Comfortable Medical Equipment for Residents
Penalty
Summary
The facility failed to provide comfortable medical equipment for two residents, R99 and R24, as observed during the survey. R99 expressed discomfort with her wheelchair, stating that her feet did not touch the ground, making it uncomfortable to sit. Despite her complaints to the nurses and aides, no action was taken to replace the wheelchair. The staff, including the Registered Nurse, Central Supply, and Restorative Director, were unaware of R99's issue, indicating a lack of communication and follow-up on the resident's needs. R99's Minimum Data Set confirmed her cognitive intactness and dependency on staff for transfers, emphasizing the importance of having suitable equipment. R24's bed was malfunctioning, with the foot of the bed stuck in an elevated position, causing her to lay crooked. This issue was observed over multiple days by different CNAs, yet it was not reported to the Maintenance Director, who stated that any staff could report equipment issues. The Maintenance Director was unaware of the problem, highlighting a breakdown in the reporting process for maintenance issues. R24's medical history includes chronic obstructive pulmonary disease, malnutrition, dementia, Alzheimer's disease, rheumatoid arthritis, anxiety disorder, and major depressive disorder, which necessitates proper equipment to ensure her comfort and safety.
Failure to Schedule Ophthalmologist Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary ophthalmologist appointment for a resident, identified as R107, who was reviewed for quality of care. R107 had been hospitalized multiple times and required ongoing eye injections as part of her treatment. Despite a physician's order dated 9/23/24 to schedule an ophthalmologist appointment as soon as possible, the appointment had not been scheduled by 10/09/24. The resident expressed frustration over the lack of follow-through by the facility, stating that she often had to remind staff or call herself to ensure appointments were made. The physician's progress note from 9/23/24 indicated that R107 was inquiring about her appointments, highlighting the importance of these follow-ups for her ongoing care. The ward clerk/scheduler admitted that scheduling the appointment was still on her to-do list, 16 days after the order was given. The ophthalmologist's office confirmed that no appointment had been scheduled and that they had not been contacted by the facility. The assistant administrator stated that the expectation was for appointments to be scheduled within a few days of the order, which was not met in this case.
Unsafe Transfer of Resident with Hemiplegia
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, identified as R95, who was reviewed for safety. R95 has a medical history that includes right-sided paralysis due to a stroke and chronic end-stage renal disease requiring hemodialysis. On October 7, 2024, at 10:15 AM, R95 was observed being transferred from a reclined chair to his bed by two Certified Nursing Assistants (CNAs), V13 and V14, after dialysis treatment. The CNAs used a gait belt to pull R95 into a standing position, despite R95 being unable to hold himself up and leaning towards his right side. The CNAs then placed their hands under R95's armpits to lift him to his bed, even though R95 was unable to bear weight or pivot during the transfer. R95's care plan, initiated on January 26, 2024, indicated that a mechanical aid (sling) should be used for transfers due to his high risk for falls and impaired mobility. A physical therapist, V16, confirmed that all residents should be transferred correctly for their safety.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident with a history of weight loss the ordered nutritional supplements, specifically fortified pudding, as part of her dietary regimen. The resident, who was admitted with diagnoses including moderate protein calorie malnutrition, Alzheimer's disease, anemia, and major depressive disorder, had an order for fortified pudding twice daily with lunch and dinner. However, during an observation on October 8, 2024, the resident's lunch tray did not include the fortified pudding, which was part of her prescribed dietary plan. The resident's weight records indicated a significant weight loss over several months, with a decrease from 160.4 lbs in April 2024 to 145 lbs by October 2024. The dietitian confirmed that the resident was supposed to receive fortified pudding and ensure plus daily, but noted that the resident often slept during meal times, which could contribute to her weight loss. The facility's policy on weights did not address insidious weight loss, which may have contributed to the oversight in providing the necessary nutritional supplements to the resident.
Failure to Conduct Comprehensive Pain Assessment
Penalty
Summary
The facility failed to perform a comprehensive pain assessment for a resident, identified as R24, who complained of significant pain. R24, who has a medical history including chronic obstructive pulmonary disease, malnutrition, dementia, Alzheimer's disease, rheumatoid arthritis, anxiety disorder, and major depressive disorder, was admitted to the facility with a care plan indicating a risk for pain related to her conditions. On two separate occasions, R24 expressed severe pain during incontinence care, rating her pain as high as 7/8 on a scale of 0-10. Despite these complaints, the nursing staff did not conduct a thorough pain assessment, including evaluating the pain's characteristics, performing a skin assessment, or assessing range of motion, before administering pain medication. On the first occasion, a CNA reported R24's pain to an RN, who administered Norco without further assessment. On the second occasion, R24 continued to express pain during care, and a Tylenol was administered by an LPN without a comprehensive assessment. The Director of Nursing later confirmed that the facility's policy requires a nurse to assess the resident's pain and perform necessary evaluations, which were not done in these instances. The facility's pain policy mandates that all residents be assessed for pain in situations where pain is likely, which was not adhered to in R24's case.
Failure to Implement Enhanced Barrier Precautions for Resident with Medical Device
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an implanted medical device, specifically a peritoneal dialysis catheter, upon admission. The resident, identified as R339, was admitted with diagnoses including dependence on renal dialysis and a complete traumatic amputation of toes. Despite the presence of a peritoneal dialysis catheter and a surgical dressing on the left lower foot, there was no EBP sign or Personal Protective Equipment (PPE) cart outside the resident's room. A Certified Nursing Assistant (CNA) was observed preparing to provide care without wearing a PPE gown, indicating a lapse in infection control measures. Interviews with facility staff revealed a lack of adherence to the facility's Infection Prevention and Control Policy, which mandates the use of gloves and gowns during high-contact care activities for residents with indwelling medical devices. The Infection Control Preventionist (ICP) acknowledged that the resident should have been placed on EBP upon admission. Additionally, a Registered Nurse confirmed that residents with implanted medical devices should be isolated upon admission, and staff should wear gowns and gloves during care. However, there was no physician order for EBP for the resident, further highlighting the oversight in implementing necessary infection control precautions.
Failure to Provide Ongoing Assessments for Resident with Injury
Penalty
Summary
The facility failed to provide ongoing assessments for a resident who had an injury of unknown origin, resulting in a significant delay in appropriate medical intervention. On 7/3/24, the resident was noted to be wincing when being changed, prompting a nurse practitioner to order an x-ray, which revealed a suspicious stress fracture in the left femur. Despite this finding, there were no documented assessments of the resident's condition from 7/4/24 to 7/7/24, and the resident remained in pain and bedbound during this period. The lack of assessments and documentation continued until 7/8/24, when the resident was finally sent to the emergency room due to abnormal behavior and inability to walk. At the hospital, the resident was diagnosed with a mildly impacted and angulated left femoral neck fracture and deep venous thrombosis, conditions that had developed while the resident was under the facility's care. Interviews with staff revealed that although the resident's pain and immobility were noted, there was a failure to conduct thorough assessments or communicate changes in the resident's condition effectively. The facility's policies required notification of significant changes in a resident's condition and ongoing assessments, but these were not adhered to in this case. The Director of Nursing acknowledged the absence of assessments and documentation, which could have identified the resident's deteriorating condition earlier. The failure to perform regular assessments and document findings contributed to the delay in addressing the resident's medical needs, ultimately leading to hospitalization and surgery.
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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 Highland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aliya Of Highwood | 1.3 mi | — | 11 | 0 |
| Whitehall Of Deerfield | 3.4 mi | — | 1 | 0 |
| Northbrook Health And Rehab | 4 mi | — | 0 | 0 |
| Lake Forest Place | 4.1 mi | — | 2 | 0 |
| Grove Of Northbrook,the | 4.5 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.