Inspection·January 10, 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 observation, interview and record review, the facility failed to follow physician order to check urine for presence of ketones for one (R1) of three residents reviewed for diabetic management. Residents Affected - Few Findings include: R1's diagnoses include but not limited to Type 1 diabetes mellitus with ketoacidosis without coma. On 01/10/2025 at 10:09 AM, R1 was observed resting in her room. R1 voiced concerns about the facility not informing her of her blood sugar levels and not checking her urine for ketones. R1's Physician Order Sheet document an order dated 12/24/2025 as follows: Ketone Test In Vitro Strip (Acetone (Urine) Test) 1 unspecified in vitro as needed for DM related to TYPE 1 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA (E10.10) To check when Accucheck is over 300 - notify MD if moderate or high. R1's January 2025 Medication Administration Record (MAR) documents the following blood sugar test results: 1/1/2025 07:30 341 miligrams per deciliter (mg/dL) 1/2/2025 07:30 314 mg/dL 1/5/2025 07:30 348 mg/dL 1/7/2025 07:30 349 mg/dL 1/8/2025 07:30 304 mg/dL 1/10/2025 07:30 350 mg/dL The January 2025 MAR excludes documentation that Ketostix test was completed. KetoStix is a ketone test that can warn you of a serious diabetes complication called diabetic ketoacidosis, or DKA. On 01/10/2025 at 10:43 AM, V5, Licensed Practical Nurse (LPN) ,stated that R1 has an order for Ketostix test to be done when blood sugar levels are above 300 mg/dl. V5 showed R1's unopened box of Ketostix Ketone strips taken from the Medication cart with a dispensed date of 12/29/2024. V5 confirmed that the box is still unopened and looked like nobody has used it yet. V5 stated that R1's blood (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 2 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 01/10/2025 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)