Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Inverness Rehab during CMS and state inspections, most recent first.
A resident with urinary retention, UTI, and a Foley catheter had physician orders for a voiding trial with PVR checks and catheter reinsertion criteria. Over one day, bladder scans repeatedly showed elevated residuals and straight catheterizations drained large urine volumes. Multiple LPNs attempted Foley reinsertion when scans remained high, but the catheters did not drain; they left a non-draining Foley in place, removed and reinserted another non-draining Foley, and did not notify the MD or NP despite the resident’s ongoing urinary retention and inability to drain urine. The NP later reported not being contacted, and the resident was subsequently sent to the hospital and admitted to the ICU with urinary retention and sepsis secondary to UTI.
Food items were found unlabeled, undated, and expired in the kitchen and in resident refrigerators, and refrigerator temperature logs were incomplete for multiple residents. Staff gave inconsistent accounts of who was responsible for checking and documenting temperatures, and a DON stated the logs were overlooked when housekeeping was not on duty. A resident with DM and obesity and another resident with dementia and GERD had food items that should have been dated or discarded, including yogurts with past use-by dates.
Respiratory Equipment Not Administered or Stored per Order: Multiple residents had oxygen, NCs, nebulizer masks, CPAP/BiPAP masks, and tubing left open to air, undated, or improperly stored at the bedside. One resident ordered continuous O2 was observed without the NC in place, and records showed oxygen was not administered daily as ordered. Staff acknowledged that respiratory equipment should be dated and stored in plastic bags for infection control.
Controlled medication counts and documentation were inaccurate for multiple residents. An LPN removed a Pregabalin dose for a resident and did not sign the narcotic record after administration, and surveyors later found mismatches between blister pack counts and the Controlled Drug Receipt Record/Disposition Forms for Lorazepam, Hydrocodone-Acetaminophen, Pregabalin, and Alprazolam. The LPN stated she had not signed the forms yet, and the DON stated nurses are expected to sign after each medication administration.
Unsecured bedside medications and an undated multidose vial were found during survey. A resident with multiple chronic conditions had a cup of meds left on the nightstand with no nurse present, and the RN later stated she left the meds at bedside without observing the resident take them. Another resident also had pills left at the bedside, with the ADON stating the pills appeared to have been spit out. Surveyors also found an open, undated vial of tuberculin PPD in the med refrigerator on Unit 3.
Infection control measures were not followed during medication administration for several residents. An LPN cut a resident’s omega-3 capsule after disinfecting a scissor but without hand hygiene or changing gloves, an ADON touched a resident and then prepared a new IV antibiotic bag without hand hygiene or glove change, and two LPNs placed glucometers directly on bedside tables without a clean barrier before finger sticks. The staff involved acknowledged the missed steps, and the facility’s policy required hand hygiene and clean barriers during these tasks.
A resident with paraplegia, CHF, morbid obesity, anemia, and a stage 4 sacral pressure ulcer was observed on a low air loss mattress set at 420 lbs even though his weight was 314 lbs. The ADON confirmed the setting, and the wound nurse stated the resident was high risk for skin alteration and sometimes directed staff to adjust the mattress. The resident had a Braden score of 12, a specialty mattress order, and a care plan for pressure injury risk.
Failure to maintain resident transfer mobility: A resident with COPD and an above-knee amputation was not on any restorative nursing program despite later documentation showing he needed partial/moderate assist with transfers. Earlier PT records showed he had been independent with bed/chair and toilet transfers, but later screening documented a decline to SBA. The MDS Coordinator stated the facility had no restorative nurse or aides, and the Therapy Director stated she was not aware of the decline.
Mechanical lift transfer not properly assisted: A resident with dementia, a history of falls, and mobility deficits required a 2-person assist for transfers, but during a lift transfer one CNA controlled the lift while the other stood on the far side of the chair and no staff member guided the resident midair. Both CNAs stated the other person should have been holding and guiding the resident's legs, and the Therapy Director confirmed that two staff should assist with the lift transfer.
A resident with a history of bipolar disorder, anxiety, and schizophrenia did not receive scheduled doses of Lorazepam because nursing staff failed to administer the medication as ordered when it was unavailable, despite facility protocol to use the emergency box. Staff confirmed the medication was not given, and documentation reflected the missed doses.
Nursing staff did not consistently perform blood glucose monitoring before meals as ordered by physicians for three residents with diabetes. Missed or delayed checks were attributed to distractions, technical issues, and lack of documentation, resulting in blood sugar levels not being monitored at the prescribed times.
A resident with dementia and depression reported to multiple staff and hospice personnel that she was inappropriately touched and possibly raped by a male staff member during a transfer. Despite these reports, the administrator did not initiate an investigation, and the facility failed to follow its abuse prevention policy requiring immediate reporting and investigation of alleged abuse.
The facility failed to administer medications timely and reorder medications for two residents, leading to missed and delayed doses. A resident with diabetes did not receive insulin on time, and another resident missed Pravastatin doses due to reordering issues. The facility's policies on medication administration and reordering were not followed, contributing to these deficiencies.
A resident with Type 1 diabetes mellitus and ketoacidosis did not receive the required Ketostix urine tests despite high blood sugar levels. The LPN did not perform the test, citing the resident's wish to sleep, and the unopened Ketostix box confirmed the test was not conducted. The DON acknowledged the lack of adherence to physician orders, and no policy on following doctors' orders was presented.
A resident with Parkinson's disease and dementia, identified as high risk for falls, experienced repeated falls resulting in injuries and hospitalization due to inadequate supervision and ineffective fall interventions. Despite a care plan that included frequent checks and positioning at the nurse's station, the facility failed to implement these measures effectively, leading to multiple incidents. Staff interviews revealed challenges in managing the resident's cognitive and behavioral issues, contributing to the falls.
The facility did not follow its policy on conducting timely background checks for new admissions, affecting four residents. Checks were delayed or incomplete, including the Criminal History Information Response Process and sex offender registry checks. Interviews with the Administrator and Medical Director confirmed the requirement for these checks to be done prior to admission to ensure resident and staff safety.
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in assistance. One resident waited 15 minutes, while another waited 41 minutes for help. Observations revealed multiple instances of delayed responses, with residents reporting waits of up to an hour. Staffing issues, such as CNAs being on break or assisting others, contributed to these delays, despite the facility's policy requiring prompt responses.
Failure to Notify Provider and Manage Urinary Retention During Voiding Trial
Penalty
Summary
The deficiency involves the facility’s failure to follow its acute change in condition policy and physician orders for managing a resident’s urinary retention and catheter care. The resident, an older female with slight cognitive impairment, was admitted with urinary retention, a UTI, and an indwelling Foley catheter. A physician order directed staff to conduct a voiding trial, perform post-void residual (PVR) bladder scans every shift for five days, and, if PVR exceeded 300 ml, to perform straight catheterization and, on the third such occurrence, reinsert a Foley catheter and follow up with a urologist. On one day, bladder scans showed residuals of 450 ml, 700 ml, and 654 ml, and staff performed straight catheterizations that drained significant urine volumes and later reinserted a Foley catheter. During the night shift, an LPN reported that a bladder scan showed a volume over 300 ml, and that after reinserting a Foley catheter it was not draining; another LPN also attempted insertion, but the catheter still did not drain. The first LPN acknowledged that the resident was retaining urine and that she did not contact the physician or urologist despite the inability to drain urine. A second LPN stated that she believed the Foley was not correctly placed and left it in to see if it would begin draining. The morning LPN removed the non-draining Foley, reinserted a new one, and again noted no drainage, but did not notify the MD or nurse practitioner. The nurse practitioner later stated that no one called to report the urinary retention or inability to drain urine, despite the clear voiding trial order. The DON stated that if multiple staff could not reinsert a Foley to drain urine, staff should notify the physician and follow their order. The resident was later sent from a urology appointment to the hospital, where she was diagnosed with urinary retention and sepsis caused by a UTI and admitted to the ICU for intensive treatment.
Food Storage and Refrigerator Monitoring Failures
Penalty
Summary
The facility failed to ensure food items in the walk-in refrigerator were labeled or dated and failed to remove expired food items from resident refrigerators. During an initial kitchen tour, surveyors observed a sandwich condiment tray in the walk-in freezer containing coleslaw salad, egg salad, lettuce, tomatoes, and sliced turkey with a use-by date of 8/15/25. The Food Service Director stated the tray should not have been in the refrigerator. The facility policy on date marking for food safety required ready-to-eat, time/temperature control for safety food to be clearly marked with the date or day by which it should be consumed or discarded, and required the head cook or designee to check the refrigerator daily for expiring items and discard them accordingly. Surveyors also found that personal resident refrigerator temperature logs were not being completed as required. R23’s temperature log was filled in only through 8/12/25, and the ADON confirmed the log was incomplete while stating temperatures were checked daily, but she did not know who was responsible for checking resident refrigerators. Similar incomplete logs were observed for R30, R65, R72, R43, and R28, with entries stopping at 8/12/25. Staff gave inconsistent statements about who checked and documented refrigerator temperatures, with one RN stating night shift documented daily and the DON stating housekeeping was responsible for daily checks and weekly cleaning, while also noting the logs were overlooked when the task was not assigned when housekeeping was not on duty. Surveyors found unlabeled, undated, and expired food in resident refrigerators. R30, a resident with type 2 diabetes mellitus and morbid obesity, had undated cut watermelon in a resealable bag. R72, a resident with unspecified dementia and GERD, had unlabeled and undated food items in a dessert cup and soup bowl, along with eight peach yogurts with use-by dates ranging from 12/30/2024 through 7/31/2025, 5/15/2025, and 5/22/2025. The RN stated these items should have been labeled and dated and that the yogurts should have been discarded before the use-by date. Review of R72’s care plan showed he tended to store food in his room or refrigerator, with interventions to check items for discard and expiration dates, but progress notes did not indicate any refusal to discard food. The facility’s resident refrigerator policy required weekly temperature logs, weekly cleaning, and discarding foods out of compliance, with noncompliance resulting in removal of the refrigerator from the resident’s room.
Respiratory Equipment Not Administered or Stored per Order
Penalty
Summary
The facility failed to ensure prescribed oxygen and respiratory equipment were administered and maintained as ordered for multiple residents. For one resident with diagnoses including diabetes, chronic kidney disease, heart failure, hypertension, anemia, atherosclerotic heart disease, and peripheral vascular disease, the resident was observed sleeping with the oxygen concentrator running at 2 LPM, but the nasal cannula was not on the resident. The humidification bottle was not labeled, the oxygen tubing was on the floor with no date or labeling, and no oxygen sign was visible on the doorway. The Director of Nursing stated nurses were expected to ensure the nasal cannula was on the resident as ordered and to check oxygen saturation levels. Record review showed the resident had an order for continuous oxygen via NC to keep SPO2 above 92%, but the oxygen was not administered daily per the physician’s order and there was no documentation of refusal. Several residents with respiratory diagnoses had respiratory equipment left open to air and not dated. One resident with COPD had an undated nasal cannula connected to an oxygen concentrator and an undated, uncovered nebulizer mask on the nightstand. Another resident with COPD had the same findings, and the RN stated the cannula and nebulizer mask should be dated when changed and the nebulizer mask should be stored in a bag after each use. A resident with COPD, sarcoidosis, and obstructive sleep apnea had an uncovered BiPAP mask on the nightstand, and a resident with asthma and obstructive sleep apnea had an uncovered CPAP mask hanging at the bedside. The RN stated these masks should be kept in a bag after each use. Additional observations showed other residents’ respiratory supplies were not stored per facility practice. One resident with hemiplegia, dementia, diabetes, obstructive sleep apnea, and dependence on other enabling devices had a CPAP machine not in use, left open to air on the cabinet, with a nebulizer mask and tubing also left open to air and not dated. Another resident with paraplegia, chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel had oxygen tubing and humidifier not dated, not stored, and hanging on the side rail. Other residents had nebulizer masks on bedside tables open to air, and one resident had a nasal cannula on the floor. Staff stated the equipment should be stored in plastic bags for infection control, and the facility policy required respiratory supplies such as nasal cannulas and nebulizer masks to be changed on schedule and stored in clean plastic bags when not in use.
Controlled Medication Counts and Documentation Were Inaccurate
Penalty
Summary
The facility failed to accurately account for controlled medications for four residents reviewed for controlled drugs. During medication administration observation, an LPN removed a Pregabalin 100 mg pill from a resident’s blister pack and later did not sign the Controlled Drug Receipt Record/Disposition Form after giving the medication. The resident was a male admitted with diagnoses including unspecified asthma and obstructive sleep apnea, and his order summary showed Pregabalin 100 mg once daily. During review of controlled medications, surveyors found discrepancies between the pill counts in the blister packs and the counts documented on the Controlled Drug Receipt Record/Disposition Forms for Lorazepam 1 mg, Hydrocodone-Acetaminophen 5-325 mg, Pregabalin 100 mg, and Alprazolam 1 mg for four residents. The LPN stated she had not signed the forms yet for the residents she had already given medications to and said she should have signed the forms after each administration. The DON stated nurses are expected to sign the Controlled Drug Receipt Record/Disposition Form after each medication administration, and also stated the LPN signed the forms before making copies.
Unsecured bedside medications and undated multidose vial
Penalty
Summary
Medications were left unsecured and not administered under direct observation for two residents. For R122, a 73-year-old male with diagnoses including type 2 diabetes mellitus, adjustment disorder with depressed mood, hypertension, heart disease without heart failure, atrial fibrillation, and peripheral vascular disease, a medication cup with multiple medications was observed left at the bedside in his room with no nurse present. R122 stated he did not know how long the medications had been on the nightstand and said he had only recently gotten out of bed to sit in his wheelchair. The ADON stated medications should not be left on the nightstand and should be administered by the nurse who prepared them. The RN initially stated she had administered the morning medications, then stated she had left the medications at bedside and did not observe the resident take them. The DON stated the RN should have observed R122 take his medication and not left the medications unsupervised at the bedside. The record showed no physician order allowing self-administration, and the medication administration audit showed 14 medications were given around 8:00 AM, yet medications were still observed in the room later that morning. For R80, a medication cup containing a round white pill and half of an oval orange pill was observed at the bedside table during unit rounds, and the same medications were still present on a later observation. The ADON stated there should not be any medications left at the resident’s bedside and that the pills appeared to have been spit out; she also stated nurses are expected to ensure residents completely swallow medications before leaving the room. In addition, during medication storage review, the Unit 3 medication refrigerator contained an open and undated vial of Tuberculin Purified Protein Derivative. The LPN stated the vial should be dated when opened and discarded 30 days after opening. Facility policy required medications to be under direct observation during administration or locked in the medication storage area/cart, and required identification of expiration dates.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to implement infection control measures during medication administration for four residents. For R21, a male admitted with hyperlipidemia, an LPN disinfected a scissor with disinfectant wipes while wearing gloves and then immediately cut the top of the resident’s omega-3 fatty acids soft gel capsule without performing hand hygiene or changing gloves. The LPN later stated she should have performed hand hygiene and changed gloves before cutting the capsule. The resident also had an order to crush medications and administer them in food or liquids unless contraindicated, along with an order for omega-3 fatty acids capsule 1000 mg daily. For R3, a male admitted with diagnoses including Klebsiella pneumonia as the cause of diseases classified elsewhere, an ADON prepared an IV antibiotic while wearing gown, gloves, and mask, then touched the resident’s right arm while waiting for a new bag of antibiotics and proceeded to prepare the new bag without performing hand hygiene or changing gloves. For R30 and R39, both female residents with type 2 diabetes mellitus, LPNs placed the blood glucose monitoring machine on the residents’ bedside tables without placing a barrier before performing finger sticks. The LPNs stated they should have used a tray or a clean barrier such as a tissue on the bedside table. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects and before preparing or handling medications, and the blood glucose testing competency required placing a clean paper towel or clean barrier on the surface.
Low Air Loss Mattress Set Incorrectly for High-Risk Resident
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility failed to ensure that a low air loss mattress was set at the correct weight setting for a resident identified as high risk for pressure injuries. The resident was a male with paraplegia, chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel. He was observed in bed awake and alert on a low air loss mattress set at 420 lbs, while he reported his weight as 314 lbs. The mattress setting was confirmed with the ADON, and the wound nurse stated that the resident was high risk for skin alteration and had a stage 4 sacral pressure ulcer. The wound nurse also stated that the resident was noncompliant with the mattress setting and at times instructed staff to adjust it. The resident’s record showed a physician order for a specialty mattress, a care plan addressing risk for skin impairment and a sacral ulcer, and a Braden score of 12 indicating high risk. The wound doctor’s note documented a stage 4 sacral wound with the objective to prevent deterioration. The facility policy stated that support surfaces are to be used in accordance with manufacturer recommendations and that pressure injury prevention should include reducing or removing underlying risk factors and modifying interventions as appropriate.
Failure to Maintain Resident Transfer Mobility
Penalty
Summary
The facility failed to provide services to maintain the highest level of mobility for one of six residents reviewed for mobility. The resident was an [AGE]-year-old male admitted on 11/24/2022 with diagnoses including chronic obstructive pulmonary disease and acquired absence of the left leg above the knee. Record review showed he was not on any restorative nursing program, even though his Functional Abilities and Goals dated 06/03/2025 indicated he needed partial/moderate assistance with chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Records also showed a change in the resident’s transfer ability over time. A Rehabilitation Screening Form dated 05/06/2025 documented his current level of assistance with transfer as standby assist, while a Physical Therapy Discharge Summary dated 01/23/2025 showed he had been independent with chair/bed-to-chair transfer and toilet transfer. During interview, the MDS Coordinator stated the facility did not have a Restorative Nurse or aides and had no residents on restorative nursing programs. The Therapy Director stated the resident had been discharged from PT as independent, that she screened residents every 3 to 4 months after discharge, and that she was not aware the resident had declined in transfer abilities; she stated that if she had known, she could have screened him and determined whether therapy was needed.
Mechanical Lift Transfer Not Properly Assisted
Penalty
Summary
The facility failed to implement interventions to reduce accident hazards and risks for one resident who was reviewed for accidents. The resident was an [AGE]-year-old female admitted on 10/17/2024 with diagnoses including history of falling, anxiety disorder, Alzheimer's disease, and unspecified dementia. Her care plan, revised 08/06/2025, indicated she had ADL self-care performance and mobility deficits and required transfer with a mechanical lift and 2-person assist. Her MDS dated 08/01/2025 indicated she was dependent with chair/bed-to-chair transfer, meaning helper does all of the effort or assistance of 2 or more helpers is required. During unit rounds on 08/19/2025 at 9:51 AM, a hospice CNA was providing incontinence care and personal hygiene assistance while another CNA responded to help with a mechanical lift transfer. The reclined chair was placed at the foot of the bed with the head part closer to the bed, and the assisting CNA stood on the farther side of the chair from the resident. The hospice CNA controlled the lift, and no staff member was guiding the resident's body midair during the transfer. In interviews, both CNAs stated that the other staff member should have been holding and guiding the resident's legs while she was midair during the transfer. The Therapy Director stated that two people should assist with a mechanical lift transfer, with one person controlling the lift and another touching and guiding the resident until the transfer is complete.
Failure to Administer Prescribed Medication Due to Unavailability and Protocol Noncompliance
Penalty
Summary
A resident with diagnoses of bipolar disorder, anxiety, and schizophrenia did not receive her prescribed Lorazepam 1.0 mg at the scheduled 9am and 1pm doses on two consecutive days. The resident noticed the missed doses when she counted her medication and found it short, prompting her to ask the nursing staff, who confirmed that the medication had not been delivered. The resident then requested to file a grievance with the Social Services Director, who assisted her and notified the Assistant Director of Nursing. Interviews with nursing staff revealed that the medication was unavailable, and although facility protocol required staff to retrieve such medications from the emergency box, this was not done. Instead, the nurses either informed their supervisor or contacted the pharmacy about the delivery, resulting in the resident missing her scheduled doses. Documentation confirmed the missed administrations, and facility policy required medications to be administered as ordered by the physician.
Failure to Perform Blood Glucose Monitoring as Ordered
Penalty
Summary
The facility failed to follow physician orders and its own policy regarding blood glucose monitoring for three residents with diabetes. Nursing staff did not consistently check blood sugar levels before meals as ordered by the physicians. Interviews with nursing staff revealed that blood sugar checks were missed or delayed, often occurring after residents had already eaten breakfast. One nurse reported being distracted by other duties and losing track of time, while another cited technical issues such as loss of internet connection. In some cases, residents refused blood sugar checks after eating, and the missed checks were not documented with reasons in the medical record as required by facility policy. Record reviews confirmed that blood glucose monitoring was not performed at the times specified in the physician orders for all three residents. The electronic medication administration records and blood sugar summary sheets showed that blood sugar checks were recorded later than the ordered times or were missed entirely. The residents involved had diagnoses of type 2 diabetes and were alert and oriented, with physician orders specifying blood sugar checks before meals and at specific times throughout the day. The facility's policy required that all physician orders be followed as prescribed and that any deviations be documented, which was not done in these cases.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with diagnoses including anxiety disorder, unspecified dementia, and major depressive disorder. The resident reported to multiple staff members and hospice personnel that a male staff member had inappropriately touched her and, at one point, stated she was raped while being transferred with a mechanical lift. The resident's sister also expressed concerns to a nurse, who reported it to the administrator. However, the administrator denied being informed of the specific allegation of rape and did not initiate an investigation, stating that the resident denied inappropriate touching when interviewed. Multiple staff interviews revealed that the resident's statements about the incident were communicated to various facility and hospice staff, including a hospice CNA, a hospice social worker, and a psychiatric nurse practitioner. Despite these reports, the information was not consistently relayed to the administrator, and no formal investigation or protective measures were initiated. The facility's policy requires immediate reporting and investigation of any suspected abuse, but this protocol was not followed in this case. Documentation reviewed included hospice communication logs and psychiatric notes, which confirmed that the resident expressed feelings of vulnerability and described being left undressed and touched inappropriately. The lack of a timely and thorough investigation, as well as the failure to remove potentially implicated staff from duty, constituted a failure to respond appropriately to an alleged violation of abuse prevention policies.
Medication Administration and Reordering Deficiencies
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents, R1 and R2, as per physician orders. R2, a resident with multiple diagnoses including type II diabetes mellitus, hypertension, depression, and anxiety, did not receive her insulin medications on time on several occasions. Observations and interviews revealed that the facility's nursing staff struggled to administer medications within the required time frame, which is one hour before and after the scheduled time. This delay in medication administration was confirmed by the facility's Medication Admin Audit Report, which showed instances where R2's insulin was administered significantly later than scheduled. Additionally, R1, a resident with diagnoses including major depressive disorder, anxiety, and diabetes, did not receive her Pravastatin medication as ordered due to a failure in reordering the medication in a timely manner. The Licensed Practical Nurse (LPN) responsible for administering R1's medication noted that the Pravastatin was missing and had to be reordered. The Director of Nursing (DON) confirmed that R1 did not receive her medication for two consecutive days and acknowledged the expectation for nurses to reorder medications when stock is low. The facility's policy on medication administration emphasizes the importance of administering medications as ordered by the physician and reordering medications when doses are running low. However, the facility's failure to adhere to these policies resulted in residents not receiving their medications as prescribed, potentially impacting their health and well-being. The use of agency nursing staff and the high number of residents per nurse were cited as contributing factors to the delays in medication administration.
Failure to Follow Physician's Order for Ketone Testing
Penalty
Summary
The facility failed to adhere to a physician's order for a resident with Type 1 diabetes mellitus with ketoacidosis without coma. The order required the use of Ketostix to check the resident's urine for ketones whenever their blood sugar levels exceeded 300 mg/dL. Despite multiple instances of the resident's blood sugar levels surpassing this threshold, there was no documentation of the Ketostix test being performed. The resident expressed concerns about not being informed of their blood sugar levels and the lack of ketone testing. An LPN confirmed that the Ketostix test was not conducted, citing the resident's preference to sleep as the reason for not performing the test. The LPN also acknowledged that the Ketostix box was unopened, indicating that the test had not been used. The Director of Nursing stated that the facility's policy is to follow physician orders and that the absence of documentation implies the test was not done. The facility did not provide a policy on following doctors' orders, and the physician was informed that the order for the Ketostix was not being followed.
Inadequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to implement effective fall interventions and provide adequate supervision for a resident, identified as R99, who was assessed as a high risk for falls due to diagnoses including Parkinson's disease and dementia. Despite being categorized as high risk for falls in multiple assessments, R99 experienced repeated falls, resulting in injuries such as lacerations and bruises, and required hospitalization on at least one occasion. The care plan for R99 included various interventions such as frequent checks, positioning at the nurse's station for closer supervision, and ensuring the environment was free of hazards, but these measures were not effectively implemented. Observations and interviews revealed that R99 was often left unsupervised or inadequately supervised, leading to multiple incidents of falls. Staff interviews indicated that while some interventions like placing a floor mat and keeping the bed in a low position were in place, they were insufficient to prevent falls. The resident's cognitive impairments, such as confusion and disorientation, along with behavioral issues like agitation and restlessness, contributed to the falls, but the facility did not adequately address these factors. The facility's fall prevention policy required individualized interventions and adequate supervision, but the implementation was lacking. Staff members acknowledged the challenges in managing R99's fall risk due to his cognitive and behavioral issues, yet there was no effective strategy in place to mitigate these risks. The repeated falls and injuries sustained by R99 highlight the facility's failure to adhere to its own fall prevention program and ensure a safe environment for the resident.
Failure to Conduct Timely Background Checks on New Admissions
Penalty
Summary
The facility failed to adhere to its policy on conducting background checks for residents upon admission, as evidenced by the cases of four residents. The policy requires that a Criminal History Background Check be requested within 24 hours after admission and that residents' names be checked on the Illinois Sex Offender Registration Website and the Illinois Department of Corrections sex registrant search page. However, for one resident, the Criminal History Information Response Process (CHIRP) was conducted two days after admission. Another resident's name was checked on the National Sex Offender website more than two months after admission, with no documentation of checks on the State Sex Offender website or the Department of Corrections. A third resident had no record of being checked under the Illinois Department of Corrections upon admission. The fourth resident's CHIRP was done four days after admission, and her name was checked on the relevant websites four months after admission, despite her being an identified offender with a history of incarceration. Interviews with the facility's Administrator and Medical Director revealed that the facility's practice is to conduct these checks prior to admission to ensure the safety of other residents and staff. The facility's policy, titled 'Abuse Prevention Policy,' outlines the procedures for pre-admission screening, including checking criminal history and sex offender registries. The failure to follow these procedures has the potential to affect all 117 residents currently residing in the facility, as it compromises the facility's ability to identify and manage potential risks associated with new admissions.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for two residents, R44 and R87, as observed by surveyors. R44, a female resident with a history of hemiplegia and hemiparesis following a cerebral infarction, activated her call light at 12:40 PM, but it was not responded to until 12:55 PM by a CNA, taking 15 minutes. R87, another female resident with a diagnosis of nontraumatic chronic subdural hemorrhage and dementia, had her call light on from 12:25 PM and did not receive assistance until 1:06 PM, resulting in a 41-minute delay. During this time, R87 was unable to access her lunch tray due to the positioning of her bedside table and required assistance to eat, as documented in her care plan. Further observations by the surveyor revealed multiple instances of call lights not being answered promptly across the facility. On one occasion, several call lights were observed going off without staff present to respond, and residents reported waiting times of 30 minutes to an hour for assistance. The Director of Nursing acknowledged the issue, stating that the expectation is for call lights to be answered within 5 minutes, but there was no system in place to track response times. The facility's policy requires all staff to respond to call lights promptly, but the surveyor noted that staffing issues, such as CNAs being on break or assisting other residents, contributed to the delays.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Inverness
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl Of Rolling Meadows,the | 2.3 mi | ★★★★★ | 5 | 0 |
| Aliya Of Palatine | 2.5 mi | ★★★★★ | 1 | 0 |
| Little Sisters Of The Poor Of Palatine | 3.1 mi | ★★★★★ | 0 | 0 |
| Encore Village | 4 mi | ★★★★★ | 12 | 0 |
| Alden Poplar Creek Rehab & Hcc | 4.1 mi | ★★★★★ | 9 | 0 |
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