Inspection·April 4, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one (R2) of three residents reviewed for quality of care received appropriate care and management for the diagnosis of diabetes, by failing to monitor R2's blood sugar levels upon admission and failing to provide continuity of care through medication administration in a total sample of six residents. Residents Affected - Few Findings include: According to R2 face sheet, R2 admission date is 2/11/2025. R2 has diagnoses that include but are not limited to type 2 diabetes mellitus; acute and chronic respiratory failure with hypoxia and hypercapnia; chronic obstructive pulmonary disease; heart failure; chronic kidney disease, stage 4. R2 care plan reads in part: Resident has the potential for hypo/hyperglycemic reactions secondary to diagnosis of diabetes mellitus, initiated 2/12/2025. 4/3/25, at 1:32 PM, V6 (Licensed Practical Nurse) stated for blood sugar checks, we go by the MAR (medication administration record), what the doctors order. They are usually taken before meals. We do have some residents that get checks four times daily because they get Lantus insulin (A slow acting insulin that is usually given on the night/evening shift). If a resident is on an insulin they should be getting blood sugar checks. You have to monitor the blood glucose level. You have to know what the blood sugar level is in order to give the insulin. Diabetics that are on oral medications do get blood sugar checks but maybe not as often as if they were on insulin. Its according to what the doctor orders. Blood sugar monitoring is dependent on what the doctor orders. 4/3/25, at 2:49 PM, V8 (Licensed Practical Nurse) stated blood sugar checks are done per the physician order. All diabetic residents should be getting blood sugar checks. You have to know where their sugar level is before giving insulin. If the sugar is low, interventions need to be implemented and notify the physician. If blood sugar level is too high the physician needs to be notified. For a diabetic resident you check the blood sugar before giving insulin. You need to check if the resident is on oral medications as well. You need to know the parameters. When the resident is admitted , if the resident is a diabetic, and if there is an order for insulin, the physician should be contacted immediately upon admission for blood sugar check and insulin administration. It is not proper for a diabetic resident not to have blood sugar checks, or not be given medications for a week after admission. If not checking the blood sugar level and still administering insulin their sugar can drop, and the resident could end up in a diabetic coma. You need to know if the blood sugar level is too high because you need to notify the physician if it is. 4/3/25, at 4:18 PM, V4 (Assistant Director of Nursing) stated the expectation is to follow doctors' orders for blood sugar checks. All the diabetics get blood sugar checks, at different frequencies. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145429 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wentworth Rehab & Hcc 201 West 69th Street Chicago, IL 60621 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)