Accolade Healthcare of Savoy

In the surveyor’s words

From the most serious findings on record at Accolade Healthcare of Savoy, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 14, 2022

  Identified failures require more than one deficient practice statement. A.) Based on interview and record review the facility failed to ensure R52, R64, and R88 were not to subjected mental, verbal, and physical abuse by R46. This failure puts these residents at risk for severe, life threatening, and potentially fatal injuries. R46, R52, R64 and R88 are four of seven residents reviewed for abuse in the sample list of 99. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/7/22, the facility remains out of compliance at severity level 2. […]

• Immediate jeopardy, patternF689Mar 29, 2021

  Failures at this level required more than one deficient practice statement. A.) Based on observation, interview, and record review, the facility failed to ensure a resident's safety while being transported in a facility van from a medical appointment. The resident (R2) slid from a wheelchair landing with buttocks on the footrests of the wheelchair which were on the floor of the van, with R2's legs extended and wheelchair tipped forward. This failure affects one of three residents (R2) reviewed for falls in the sample of three. R2 sustained excruciating pain to bilateral lower extremities, immediately after and with movement after the fall on the van, prior to being diagnosed with bilateral femur fractures identified to be consistent with a traumatic incident or fall. […]

• Immediate jeopardy, isolatedF600Jun 26, 2023

  Based on observation, interview, and record review the facility failed to supervise a resident (R1) with a known history of wandering, evaluate or assess residents' capacity or ability to consent to sexual activity, and identify resident to resident sexual activity as nonconsensual sexual abuse for three of five residents (R1, R2, R3) reviewed for abuse in the sample list of ten. This failure resulted in R1 sexually abusing R3, and R3 sexually abusing R1. The Immediate Jeopardy began on 6/13/23 when R1 wandered into R3's room resulting in R1 sexually abusing R3, and R3 sexually abusing R1. V1 Administrator was notified of the Immediate Jeopardy on 6/21/23 at 2:44 PM. […]

• Immediate jeopardy, isolatedF686Jul 1, 2022

  Based on observation, interview, and record review, the facility failed to sanitize scissors prior to a pressure ulcer dressing change, failed to document completion of pressure ulcer treatments, and failed to document weekly skin checks. These failures affect one resident (R1) on the sample of seven. Findings include: 1.) On 6/30/22 at 10:30 am, V5, Licensed Practical Nurse, conducted a pressure ulcer dressing change for R1. During this dressing change, V5 stated, I forgot my scissors, then requested for V18, Certified Nursing Assistant to go out to the treatment cart and retrieve the scissors. […]

• Actual harm, patternF740Sep 14, 2022

  Based on interview and record review the facility failed to comprehensively assess a resident's aggressive behaviors upon admission for one of one resident (R46) reviewed for behaviors in the sample list of 99. This failure has the potential to affect 65 residents (R36, R42, R164, R365, R47, R88, R109, R17, R79, R92, R37, R18, R69, R3, R71, R22, R366, R76, R9, R64, R49, R63, R30, R67, R60, R72, R40, R57, R105, R113, R50, R85, R54, R44, R86, R48, R38, R23, R96, R16, R104, R12, R2, R53, R20, R78, R70, R33, R59, R5, R34, R6, R82, R32, R81, R13, R103, R110, R56, R29, R91, R77, R95, R55, R165) residing on the second floor of the facility. […]