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.
(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
06/20/2025
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145994
If continuation sheet
Page 2 of 2
