Fair Havens Senior Living: Diabetic Coma Hospitalization - IL
The resident, identified as R7, was admitted to the facility for therapy with plans to return home. She had been diagnosed with heart failure and Type 2 diabetes with hyperglycemia.
Her discharge plan specifically stated "Blood Glucose monitoring - check blood sugar before meals and at bedtime." But the nursing home never transcribed that order into her medical record.
On the morning she was rushed to the hospital, Licensed Practical Nurse V21 found R7 "not acting herself" at 6:00 am during routine care. When V21 attempted to check her blood glucose, the meter couldn't register a reading. It simply displayed "high."
The hospital documented R7's condition upon arrival: altered mental status, sweating, clammy skin, and a temperature of 102.4 degrees. Her blood glucose measured over 600 mg/dl when first tested, with laboratory results confirming 738 mg/dl.
R7 was diagnosed with diabetic ketoacidosis and a urinary tract infection.
Licensed Practical Nurse V22 called the hospital later that day to check on R7's condition and learned of her admission. But no documentation exists showing V22 completed the required SBAR form to communicate with physicians about R7's deteriorating condition before her hospitalization.
Practical Nurse V28 confirmed during interviews that nursing assistants are expected to notify nurses when residents have loose stools, and nurses should then contact physicians. V28 acknowledged finding documentation of loose stools and diarrhea in R7's medical record.
V28 also confirmed that V22 should have called the physician after completing an SBAR communication form, but no such form existed in R7's record.
The facility had physician orders for R7 to receive 10 units of insulin glargine subcutaneously once daily, starting at 9:00 am. But the critical blood glucose monitoring order from her discharge plan never made it into her active medical record.
Director of Nursing V3 and Assistant Director of Nursing V4 confirmed during interviews that R7's transfer physician orders documented the blood glucose monitoring requirement. They also confirmed the order was missing from her medical record at the facility.
Licensed Practical Nurse V21 told inspectors that R7's blood glucose readings "were elevated at times" before the hospitalization. This suggests staff were aware of concerning patterns but may not have been monitoring as frequently as ordered.
R7's primary care physician, V16, explained that her dangerously elevated blood glucose on the morning of hospitalization was likely secondary to infection and would have been elevated at bedtime the night before if proper monitoring had occurred.
The facility's own documentation shows nurses have access to bowel and bladder charting systems and can review how residents are being monitored. Yet the systematic failure to implement the glucose monitoring order meant R7's condition went undetected until she developed life-threatening ketoacidosis.
Diabetic ketoacidosis occurs when blood sugar levels become dangerously high and the body begins breaking down fat for energy, producing toxic ketones. Without prompt treatment, the condition can lead to coma or death.
Normal blood glucose levels typically range from 80 to 130 mg/dl before meals. R7's reading of 738 mg/dl was nearly six times the upper limit of normal ranges.
The inspection found that Fair Havens failed to ensure physician orders were accurately transcribed and implemented for blood glucose monitoring. This failure resulted in actual harm to R7, requiring emergency hospitalization that might have been prevented with proper monitoring.
R7 had been admitted to Fair Havens for rehabilitation therapy with the goal of returning home. Instead, she required emergency medical intervention for a preventable diabetic emergency that developed under the facility's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Havens Senior Living from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
FAIR HAVENS SENIOR LIVING in DECATUR, IL was cited for violations during a health inspection on August 13, 2025.
The resident, identified as R7, was admitted to the facility for therapy with plans to return home.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.