Landmark of Richton Park: Insulin Failure Harms Resident - IL
The resident, identified in inspection records only as R2, was supposed to receive a sliding scale dose of Lispro, a fast-acting insulin, at 9 p.m. that night. Her blood sugar reading of 400 was the precise threshold at which the facility's own policy required staff to notify the physician immediately and contact the resident's representative. It was also the number above which the sliding scale no longer applied, meaning the situation had moved beyond what a nurse could handle with a standing order alone.
The nurse, identified as V5, gave Lantus instead. Lantus is a long-acting insulin. It is not the same drug, and it was not what the physician ordered for that moment.
When a federal surveyor later asked V5 which insulin she had given R2 at 9 p.m., V5 said she had given Lantus because R2 "gets Lantus at night." When the surveyor asked whether she had notified a supervisor, identified as V7, about the critical blood sugar reading at 9 p.m., V5 explained that she had called V7 twice earlier in the evening, at 5 p.m. and again about a half hour later, about an earlier blood sugar reading. But at 9 p.m., she said, she didn't call because R2 "was within the limits to give her a sliding scale."
She was not. A blood sugar of exactly 400 falls outside sliding scale parameters, not within them.
V5 told the surveyor she covered the reading "with the sliding scale because she was under 400." The medication administration record told a different story. The MAR documented that Lispro, the ordered insulin, was not given. The number 9 entered on the record confirmed the omission.
The surveyor pressed again, noting the inconsistency in V5's statements. V5 repeated that she had given Lantus. She also acknowledged she had made no note about the 9 p.m. blood sugar reading or what she had done in response to it. "For the 9pm, I just give her the insulin," V5 said. "I didn't make a note."
The facility's own blood glucose monitoring policy, though undated, is unambiguous. Blood sugars below 70 or above 400 are to be reported immediately to the physician and the resident's representative. Any orders received from the physician are to be carried out. Nursing interventions for hyperglycemia are to follow sliding scale parameters for fast-acting insulin, with additional physician orders as needed. Documentation is required.
None of that happened. The physician was not called. The resident's representative was not contacted. The ordered insulin was not given. No note was written.
The inspection was conducted on September 8, 2025, following a complaint. Federal inspectors classified the violation under F0600, which covers abuse and neglect, at a level of actual harm affecting a small number of residents. That classification reflects a determination that R2 was not merely at risk of harm, but that harm had already occurred.
Landmark of Richton Park is disputing the citation.
A blood sugar of 400 in a diabetic patient is not a borderline reading. It signals hyperglycemia severe enough that the body cannot regulate itself, and left unaddressed, it can lead to diabetic ketoacidosis, a condition that causes nausea, vomiting, confusion, and, without intervention, can become life-threatening. The physician who ordered the sliding scale Lispro did so precisely because fast-acting insulin is required when blood sugar climbs that high. Lantus, the drug V5 gave instead, works over 24 hours. It does not address a crisis in the moment it is happening.
What V5 told the surveyor, across multiple rounds of questioning, never fully lined up. She said R2 was within sliding scale limits. The reading said she wasn't. She said she gave the sliding scale. The MAR said Lispro wasn't given. She said she called V7 about the 9 p.m. reading. Then she explained she hadn't, because R2 was "within the limits." She gave Lantus. She made no note. She moved on.
R2 spent that night with a blood sugar of 400, the wrong insulin in her system, the right one withheld, and no physician aware that anything had happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark of Richton Park Rehab & Nsg Ctr from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
LANDMARK OF RICHTON PARK REHAB & NSG CTR in RICHTON PARK, IL was cited for violations during a health inspection on September 8, 2025.
The resident, identified in inspection records only as R2, was supposed to receive a sliding scale dose of Lispro, a fast-acting insulin, at 9 p.m.
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.