Immaculate Mary Center: Blood Sugar Crisis Ignored - PA
The resident, identified in inspection records only as R1, had an active order requiring staff to notify a physician any time blood glucose climbed above 250. On August 5, it hit 260. On August 16, it reached 324. On August 26, it peaked at 333. Across the month, inspectors found 14 documented readings above 250, each logged at the same afternoon hour, each apparently reviewed by nursing staff, and each met with silence.
Nobody called.
The situation was more specific than a general failure to manage a chronic condition. R1 was also being treated for serious foot wounds, including a deep tissue injury on the right plantar surface covered in dry eschar, and a left foot wound with granulation tissue, drainage, and surrounding redness. The podiatrist treating those wounds flagged the blood sugar problem directly. On August 7, the podiatrist recommended keeping glucose below 180, recognizing that elevated blood sugar impairs wound healing and raises infection risk.
After that recommendation, staff recorded 43 blood glucose readings. Thirty-nine of them were above 180.
The clinical record for the three weeks following the podiatrist's warning contained no documentation that the physician was notified of the elevated readings, no record of any attempt to adjust R1's diet, and no record of any change to medications. The inspection report found no evidence the facility tried anything at all.
On August 29, R1 was taken to a doctor's appointment. The appointment ended with a trip to the emergency room. The hospital admitted the resident with osteomyelitis, a bone infection, one of the most serious complications that can develop when diabetic wounds go uncontrolled.
The Director of Nursing, interviewed by inspectors on September 15, confirmed what the records already showed. The podiatry recommendation for diabetic management had not been addressed. Staff had not notified the physician of the elevated blood sugar. The director offered no alternative account.
The inspection was classified as a complaint survey, meaning someone had raised a concern that triggered the visit. Inspectors cited the deficiency under F0684, which covers the standard that residents receive care in accordance with professional standards of practice. CMS rated the level of harm as minimal harm or potential for actual harm, a designation that reflects regulatory category rather than the resident's outcome. R1 was hospitalized with a bone infection.
What the record shows is a gap that lasted 22 days. From August 7, when the podiatrist put the target in writing, to August 28, the last reading before hospitalization, no documented intervention occurred. The physician whose order governed the blood sugar threshold, the one requiring notification above 250, was apparently never reached on any of the days the threshold was crossed. The order existed. The crossings were recorded. The calls were not made.
Osteomyelitis in diabetic patients with foot wounds is not an unpredictable complication. It is a known risk, the reason podiatrists and wound care protocols emphasize glycemic control in the first place. Bone infections are difficult to treat, often requiring weeks of intravenous antibiotics and, in severe cases, surgical intervention.
The inspection report does not describe R1's condition after hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Immaculatemarycenter For Rehabilitation&healthcare from 2025-09-15 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 28, 2026 · Our methodology
IMMACULATEMARYCENTER FOR REHABILITATION&HEALTHCARE in PHILADELPHIA, PA was cited for violations during a health inspection on September 15, 2025.
The resident, identified in inspection records only as R1, had an active order requiring staff to notify a physician any time blood glucose climbed above 250.
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.