Health inspection·June 20, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to ensure that blood glucose monitoring for three (R1, R3, R4) of three residents reviewed for blood sugar monitoring were checked before meals per the physician order. Residents Affected - Few Findings include: On 6/17/2025 at 3:12 PM, V3 (RN) said that today is V3 first day work with R1. V3 said he first entered R1's room after 11:00 AM. V3 said that he was supposed to check R1's blood pressure and blood sugar. V3 said that the blood pressure and blood sugar was supposed to be done in the morning. V3 said that he had 29 residents, V3 said that he lost tract because the CNA was asking him for help with different residents. V3 said that he also lost internet between 9:30 AM and 10:00 AM check. V3 said that blood sugar checks were supposed to be done before breakfast. V3 said that by the time V3 lost internet connection, the residents had already eaten breakfast. V3 said that R1 refused for her blood sugar and blood pressure to be checked because she already ate breakfast. V3 said that blood sugar should be checked before the residents eat breakfast. On 06/18/2025 at 12:23 PM, V7 (RN) said that V7 have residents that have diabetes. V7 said that the residents blood sugar level was supposed to be checked before meals per doctors' order. V7 reviewed R4 blood sugar administration record with surveyor and observed that some blood sugars for R4 were not done on time per doctor's order. On 6/18/2025 at 4:12 PM V9 (LPN/Weekend Supervisor), said that V9 obtained R1's blood pressure reading on 5/23. V9 said that the blood sugar was not done because R1 has already eaten breakfast V9 said that the blood sugar check was to be done before breakfast. R1 is a [AGE] year-old female admitted on [DATE] with a brief interview of mental status (BIMS) score of 15/15. R1 admission diagnosis include type 2 diabetes and primary hypertension. R1's physician order indicate that blood sugar was ordered to be checked in the morning. R1s' electronic medication administration record indicate that R1 blood sugar should be checked at 8:00 AM. R1s' blood sugar summary sheet has blood sugar check recorded later than 8:00 AM per physician order. R3 is a [AGE] year-old-male admitted to the facility on [DATE]. R3 is alert and oriented with BIMS score of 15/15 and able to make her needs known. R3 physician order indicates that R3's blood sugar is to be checked in the morning. R3 electronic medication sheet indicates that R3 blood sugar is to be checked at 08:00 am; 12:00 pm; and 17:00 pm. R3 blood sugar record sheet indicates some R3's blood sugar check were not done per the physician's order. Page 1 of 2 145994 145994 06/20/2025 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0684 Level of Harm - Minimal harm or potential for actual harm R4 is a [AGE] year-old-female admitted to the facility on [DATE] with a brief interview of mental status (BIMS) of 13/15. R4 physician order sheet indicates that blood sugar check is ordered to be done before meals and at bedtime. R4's electronic medication sheet has blood sugar check scheduled for 06:30 am, 11:30am, and 16:30 pm. R4's blood sugar record sheet indicates that some of R4's blood sugars were not checked per the physician order. Residents Affected - Few Physician Orders Policy: A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. Policy Explanation and Compliance Guidelines: 4. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on resident's medical record during that shift. ACCUCHECK /BLOOD GLUCOSE MONITORING POLICY: It is the policy of this facility to perform accuchecks (BGM) as ordered by the resident's physician and to report alert levels to the attending physician as warranted. Standard parameters are as follows: Blood glucose level <60 or > 400 unless otherwise specified by the physician. PURPOSE: To assure that residents' blood sugar levels are appropriately monitored and to establish parameters for nursing interventions. PROCEDRE: 2. All accuceck orders will be implemented by nursing staff per physician order. All orders for insulin (sliding scale, etc,) will be implemented per physician order. 145994 Page 2 of 2