Accolade Healthcare Of Savoy

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility repeatedly failed to notify the Physician of one (Resident R1) resident's elevated glucose levels out of three residents reviewed for Quality of Care in a sample list of eight residents.Findings include:Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R1 as severely cognitively impaired. Resident R1's Physician Order Sheet dated August documents a physician order to obtain Resident R1's blood glucose levels twice daily. Resident R1's Electronic Medical Record (EMR) does not show that V17 (Resident R1's) Physician was notified of Resident R1's blood glucose levels above 200 mg/dl.Resident R1's Medication Administration Record (MAR) dated August 2025 document Resident R1's blood glucose level were:8/12/25 at 5:00 PM was 2138/18/25 at 9:00 AM was 2208/19/25 at 9:00 AM was 2728/20/25 at 9:00 AM was 2488/23/25 at 9:00 AM was 2858/24/25 at 9:00 AM was 3008/24/25 at 5:00 PM was 2068/25/25 at 9:00 AM was 2988/25/25 at 5:00 PM was 2218/26/25 at 9:00 AM was 3068/27/25 at 5:00 PM was 2218/28/25 at 5:00 PM was 2358/29/25 at 9:00 AM was 3508/29/25 at 5:00 PM was 229.On 9/23/25 at 1:00 PM V2 Director of Nurses (DON) stated staff should notify the physician for any resident that has their blood glucose checked who is not on Insulin whose blood glucose level is less than 50 milligrams (mg)/deciliter (dl) and greater than 200 mg/dl. On 9/18/25 at 3:00 PM V5 Nurse Practitioner stated Resident R1's elevated blood glucose levels should have been reported per the facility policy. V5 NP stated Resident R1's elevated glucose levels were ‘predominantly' due to his diet that was supported by Resident R1's spouse. V5 NP stated V5 would not have made any changes to Resident R1's medicines or treatment plan due to Resident R1's elevated blood glucose levels.The facility policy titled Blood Glucose Monitoring revised June 2023 documents staff are to report any reading below 50 or above 200, or per physician ordered parameters.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Accolade Healthcare of Savoy

302 West Burwash Savoy, IL 61874

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to check the placement of one (Resident R3) resident's Gastrostomy Tube (G-Tube) prior to administering medication out of eight residents reviewed for medication administration in a sample list of eight residents. Findings include:Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R3 as severely cognitively impaired. This same MDS documents Resident R3 as being dependent

on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.Resident R3's Physician Order Sheet (POS) dated September 2025 documents a physician order for Resident R3 to not take any foods/medications by mouth (NPO). This same POS documents a physician order starting 8/15/25 to administer Jevity 1.5 calorie/Fiber Oral Liquid (Nutritional Supplements) Give 240 milliliters (ml) via Gastrostomy tube (G-Tube) four times a day for Dysphagia. This same POS documents a physician order starting 8/15/25 to check G-Tube residual amount and record before administering feeding every shift. If 100 milliliters (ml) or greater, hold feeding and notify Physician. Resident R3's Care Plan intervention dated 8/14/25 documents check for tube placement and gastric contents/residual volume per facility protocol and record.On 9/19/25 at 7:50 AM V22 Licensed Practical Nurse (LPN) did not check the placement of Resident R3's Gastrostomy tube (G-tube) prior to administering Resident R3's scheduled water flushes of 150 milliliters (ml), liquid nutritional bolus feeding and morning medications.On 9/19/25 at 8:00 AM V22 Licensed Practical Nurse (LPN) stated all of the water flushes, medications and nutritional feeding could have been forced into Resident R3's abdominal cavity outside her stomach due to V22 not checking the placement of Resident R3's G-Tube first. V22 LPN stated that could cause Resident R3 gastrointestinal (GI) distress, malabsorption and/or a significant clinical decline

in condition resulting in a possible emergency room visit. On 9/23/25 at 9:00 AM V2 Director of Nurses (DON) stated V22 LPN should have checked the placement of Resident R3's G-Tube prior to administering any medications, water flushes and/or nutritional feeding bolus. V2 DON stated there is no way to tell if the medications, water flushes and nutritional feeding went into Resident R3's stomach if the nurse does not check for gastric residual. V2 DON stated not checking the placement of G-Tube prior to administering anything could result in a 'very bad' situation for that resident. The facility policy titled Tube Feeding revised February 2024 documents check the (G-Tube) for proper placement before administering medications.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Accolade Healthcare of Savoy

302 West Burwash Savoy, IL 61874

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759

Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility repeatedly failed to administer one (Resident R2) resident's Latanoprost 0.05% eye drop medication as prescribed out of five residents reviewed for medication administration in a sample list of eight residents.Findings include:Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R2 as cognitively intact.Resident R2's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 8/15/25 to administer Latanoprost 0.005% eye drops, one in each eye at bedtime for eye deficiencies. Resident R2's Care Plan intervention dated 8/15/25 instructs staff to Administer medication per orders.Resident R2's undated Pharmacy medication fill report documents Resident R2's Latanoprost Ophthalmic solution 0.005% eye drops have an original date of 8/15/25 and fill dated of 8/26/25 and 9/12/25. Resident R2's Medication Administration Record (MAR) dated August 2025 documents Resident R2's Latanoprost 0.005% Ophthalmic Solution eye drops was not administered on 8/15, 8/16, 8/18 and 8/20-8/25/25 due to medication not available.On 9/19/25 at 10:25 AM Resident R2 stated he is supposed to get Latanoprost eye drops for his Glaucoma. Resident R2 stated he did not receive his Latanoprost for the first ten days of his stay. Resident R2 stated he asked the nursing staff and was told it was on order. Resident R2 stated his Glaucoma could be getting worse if he does not take his eye drops as his Ophthalmologist prescribes. On 9/23/25 at 9:05 AM V2 Director of Nurses (DON) stated Resident R2 did not have his Latanoprost Ophthalmic eye drops 0.005% for the first ten days of his admission.

V2 DON stated Latanoprost eye drops are given to help reduce the blood pressure in Resident R2's eyes for Glaucoma.The facility policy titled Administration of Medications revised August 2023 documents residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility policies.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Accolade Healthcare of Savoy

302 West Burwash Savoy, IL 61874

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to follow Infection Control Procedures for one (Resident R3) resident on Enhanced Barrier Precautions (EBP) out of five residents reviewed for medication administration in a sample list of eight residents.Findings include:Resident R3's Physician Order Sheet (POS) dated September 2025 documents a physician order for Resident R3 to not take any foods/medications by mouth (NPO).

This same POS documents a physician order starting 8/14/25 for staff to utilize Enhanced Barrier Precautions (EBP) every shift during high contact care activities that provides opportunities for transfers of Multi Drug Resistant Organisms (MDRO) from/to high-risk residents with wounds and/or indwelling medical devices that are at especially high risk for both acquisition of and colonization of MDRO's. Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R3 as severely cognitively impaired. This same MDS documents Resident R3 as being dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. Resident R3's Care Plan intervention dated 8/14/25 documents (Resident R3) is on Enhanced Barrier protection related GTUBE to reduce transmission of resistant organisms that employs targeted gown and glove use

during high contact resident care activitiesOn 9/19/25 at 7:49 AM Resident R3's room door had a sign posted that indicates Enhanced Barrier Precautions (EBP). There was Personal Protective Equipment (PPE) available outside Resident R3's room door. On 9/19/25 at 7:51 AM V22 Licensed Practical Nurse (LPN) did not wear a gown when administering Resident R3's water flushes, medications and nutritional bolus feeding through Resident R3's Gastrostomy Tube (G-Tube). On 9/19/25 at 8:05 AM V22 Licensed Practical Nurse stated she knew that Resident R3 was on Enhanced Barrier Precautions (EBP) and should have worn a gown when administering medications through Resident R3's Gastrostomy tube (G-Tube). On 9/23/25 at 9:00 AM V2 Director of Nurses (DON) stated V22 LPN should have checked the placement of Resident R3's G-Tube prior to administering any medications, water flushes and/or nutritional feeding bolus. V2 DON stated there is no way to tell if the medications, water flushes and nutritional feeding went into Resident R3's stomach if the nurse does not check for gastric residual.

V2 DON stated not checking the placement of G-Tube prior to administering anything could result in a 'very bad' situation for that resident. V2 DON stated V22 should have worn the required Personal Protective Equipment (PPE) when administering medications through Resident R3's G-Tube.The facility policy titled Infection Control Enhanced Barrier Precautions (EBP) reviewed October 5, 2024, documents EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi Drug Resistant Organisms (MDRO)'s to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. High-contact resident care activities requiring gown and glove use among residents that trigger EBP use include device care or se: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet