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Inspection visit

Health inspection

INVERNESS REHABCMS #1459941 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

145994 01/10/2025 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067
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 Page 1 of 2 145994 145994 01/10/2025 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sugar level was 350 mg/dL this morning but V5 did not use the Ketostix strip to check R1's urine for Ketones because R1 didn't want to check it at that time because R1 wanted to sleep some more. V5 also stated that Ketone test results should be documented in the Medication Administration Record (MAR). V5 confirmed that the January 2025 MAR excludes any Ketostix results. 01/10/2025 at 1:47 PM V2, Director of Nursing (DON) stated The facility policy is to make sure we follow the physician orders. I expect the nurses to follow the doctor's order. If it's not marked, if it's not documented, it wasn't done. If blood sugar levels are running that high, there is a danger for diabetic keto acidosis. KetoStix is used to find out if there's ketones in the urine, if there's high levels of ketone in the urine, it can be life threatening. 01/10/2025 at 3:00 PM V2, Director of Nursing (DON) stated that she has informed the doctor that the physician order for the Ketostix was not being performed as ordered and that the order for the Ketostix has been discontinued. Facility did not present a policy on following doctors' orders. 145994 Page 2 of 2

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Citations

1 citation 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.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ · About this visit

Common questions about this visit

What happened during the January 10, 2025 survey of INVERNESS REHAB?

This was a inspection survey of INVERNESS REHAB on January 10, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at INVERNESS REHAB on January 10, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

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

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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.