Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews and record reviews, the facility failed to ensure call lights were answered in a timely
manner for two (R44 and R87) of two residents in a sample of 44 reviewed for accommodation of needs.
Residents Affected - Few
Findings include:
R44 is a [AGE] year old, female, initially admitted in the facility on 08/21/2017 with diagnosis of Hemiplegia
and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side; and Cerebral Infarction,
Unspecified.
On 07/08/24 at 12:40 PM, R44 pushed the call light. At 12:50 PM, her call light was observed still on. R44
stated, I want my CNA (Certified Nursing Assistant). I want to get up now. At 12:55 PM, observed V14
(CNA) go to R44's room and respond to her call light. It took 15 minutes for V14 to respond to R44's call
light.
R87 is a [AGE] year old, female, initially admitted in the facility on 11/21/2023 with diagnosis of
Nontraumatic Chronic Subdural Hemorrhage; Dementia in other Diseases Classified Elsewhere,
Unspecified Severity, with Other Behavioral Disturbance; and Multiple Fracture Ribs, Left Side, Subsequent
Encounter for Fracture with Routine Healing.
On 07/08/24 at 12:25 PM, R87's call light was observed on. It was observed that there were no staff
present in the hallway and by the nurses' station. At 12:40 PM, her call light was still on. Surveyor went to
R87's room, observed lunch tray at bedside table. Bedside table was situated at the foot of the bed. R87
stated I tried to call to turn that table around so I can eat but I still have no assistance. V11 (Licensed
Practical Nurse, LPN) was observed sitting at the nurses' station. At 12:59 PM, V15 (CNA) was collecting
food trays in the hallway where R87's room can be found. Surveyor observed that V15 left and went to other
unit. V15 did not go to R87's room. At 1:00 PM, R87's call light was still on. V13 (Housekeeping) was
observed in R87's room. V13 was observed going to the nurses' station and talked to V11. V13 was asked if
she told V11 about R87's call light. V13 stated, I told her (V11) and she said that one CNA is attending
other residents. At 1:06 PM, R87's call light was still on, V11 was observed going to R87's room to provide
assistance. It took 41 minutes for a staff to respond to R87's call light. R87's care plan documented: ADL
(Activities of Daily Living) self-care performance deficit - Interventions - eating: one-person assist;
encourage to use call light to call for assistance.
On 07/09/24 at 1:19 PM, V2 (Director of Nursing, DON) was interviewed regarding call lights. V2 stated, We
received complaints from residents regarding call lights. We do staff in-services regarding responding to
call lights; department heads do rounds on a daily basis during morning shift ensuring
(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 4
Event ID:
145994
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
145994
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inverness Rehab
1800 W Colonial Parkway
Inverness, IL 60067
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)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
call lights are responded. Staff on the floor do rounds at least every two hours and as frequent as needed.
Reasonable time to respond to call light is not more than 5 minutes. Any staff in the facility should respond
to call lights. I have talked to housekeeping and kitchen staff to not respond related to care but at least
respond to call lights. If they responded to call lights and its related to care, they have to notify the nurse.
On 07/8/24 at 11:00 AM to 11:30AM during observation in unit one of the facilities, observed several call
lights going off in resident's rooms that were not answered promptly, some resident's beds were noted with
no linens and stripped naked.
On 07/9/24, between 9:46AM and 10:30AM, surveyor observed several call lights turned on in the 200
section of unit one with no staff observed answering responding to them. Surveyor responded to one of the
lights and notified staff that resident needs to go to the bathroom. Several residents screened had concern
with the call light not being answered in a timely manner, some residents said that it takes 30 mins to one
hour for the call light to be answered.
On 07/9/24 at 11:20 AM, V8 (Registered Nurse, RN) was presented with this observation, and she said that
there are two CNA's that are assigned to the unit, one just went on break and the other one is probably in
another room. Surveyor asked V8 why the call lights are not being answered in a timely manner and she
said, The CNA's are usually pulled to help with lunch, right now one of them is on break and the other one
is probably assisting another resident.
On 07/9/24 at 1:15PM, V2 (DON), said call light response has been a concern and the expectation is that it
should be answered in a timely manner, they provide in-service to staff and the department heads also do
angel rounds during the day, the facility does not have managers in the evening so the floor nurses and
CNA's will be responsible for monitoring the call light and ensuring that it is answered timely. V2 was asked
to be a little more specific on what is considered timely, and she said within 5 minutes. The facility does not
have any system in place to show how long a call light has been on before it was answered. She added that
when a call light is on, any staff can answer it, even if they cannot provide the type of assistance that the
resident needed, at least they can get the right person to assist the resident.
Facility's policy titled, Call light Policy, dated 1-28-23 stated in part but not limited to the following:
Purpose: To respond to the resident's requests and needs in a timely manner.
Performed by: All Staff
Procedure:
1. Answer call light promptly and turn the light off after entering the room. Knock on the door before
entering.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145994
If continuation sheet
Page 2 of 4
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
145994
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inverness Rehab
1800 W Colonial Parkway
Inverness, IL 60067
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)
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow its policy on conducting background checks for four
(R52, R103, R105 and R106, ) of 10 residents reviewed for admission screening. This failure has the
potential to affect 117 residents currently residing in the facility.
Residents Affected - Many
Findings include:
Per census report, there are 117 residents currently residing in the facility.
R52 is a [AGE] year old, female, admitted in the facility on 06/15/24 with diagnosis of Unspecified Fracture
of Shaft of Humerus, left Arm, Subsequent Encounter for Fracture with Routine Healing. R52's Criminal
History Information Response Process (CHIRP) was done on 06/17/2024, two days after admission.
R103 is [AGE] year old, male, initially admitted in the facility on 01/05/24 with diagnosis of Unspecified
Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance,
and Anxiety. R103's name was checked in the National Sex offender website on 03/30/2024, which was
more than two months after admission. There was no documentation that R103's CHIRP was checked, nor
his name checked under State Sex offender website and Department of Corrections.
R105 is a [AGE] year old, female, admitted in the facility on 06/24/24 with diagnosis of Sepsis, Unspecified
Organism. There was no record that her name was checked under Illinois Department of Corrections upon
admission.
R106 is a [AGE] year old, female, admitted in the facility on 03/01/24 with diagnoses of Anorexia; Adult
Failure to Thrive and Major Depressive Disorder, Recurrent, Unspecified. Her CHIRP was done on
03/05/24, which was four days after admission. R106's name was checked in the Illinois Department of
Corrections, State and National Sex offender websites on 07/09/24, which was four months after she was
admitted . R106 is an identified offender for criminal offenses and had history of incarceration.
On 07/09/24 at 3:05 PM, V1 (Administrator) was asked regarding background checks on residents. V1
stated, For new admissions regarding background checks, the team is notified that we have to check with
National and State sex offender websites and the department of corrections. We have to do those prior to
admission. CHIRP is done within 24 hours of admission. We want to make sure if there is a hit for sex
offenders so we could provide a private room.
V20 (Medical Director) was also asked on 07/10/24 at 4:27 PM regarding background checks. V20
verbalized, Regarding screening of new residents, they should be screened prior to admission to facility for
background checks and at sex offender websites. We want to make sure they are not a danger to other
residents and other staff.
Facility's policy titled, Abuse Prevention Policy, dated 9/28/23 documented in part but not limited to the
following:
Procedures:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145994
If continuation sheet
Page 3 of 4
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
145994
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inverness Rehab
1800 W Colonial Parkway
Inverness, IL 60067
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)
F 0607
II. Pre-admission Screening of Potential Residents
Level of Harm - Minimal harm
or potential for actual harm
This facility shall check the criminal history background on any resident seeking admission to the facility in
order to identify previous criminal convictions.
Residents Affected - Many
This facility will:
Request Criminal History Background Check within 24 hours after admission of a new resident
Check for the resident's name on the Illinois Sex Offender Registration Website
Check for the resident's name on the Illinois Department of Corrections sex registrant search page
While the background or fingerprint checks, and/or Identified Offender Report and Recommendations are
pending, the facility shall take all steps necessary to ensure the safety of residents.
Facility's policy titled, admission of Identified Offender, dated 5/3/22, stated in part but not limited to the
following:
Guidelines:
1. Screened on Sex offender website.
2. Criminal History record information requested.
4. Facility must review screenings and all supporting documentation to determine if the placement is
appropriate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145994
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
FAQ · About this visit
Common questions about this visit
What happened during the July 11, 2024 survey of INVERNESS REHAB?
This was a inspection survey of INVERNESS REHAB on July 11, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at INVERNESS REHAB on July 11, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.