Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 4 | 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 | — | 1 | 0 |
| Alden Poplar Creek Rehab & Hcc | 4.1 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.