Savoy Care Center

In the surveyor’s words

From the most serious findings on record at Savoy Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 28, 2025

  Based on interview, observation, and record review the facility failed to ensure residents' rights to be free from verbal abuse and psychosocial harm by staff (Resident #15), resident to resident physical abuse (Resident #51 and #6); and protect a resident's right to be free from neglect (Resident #68), for 4 (Residents #6, #15, #51, and #68) of 4 residents (#6, #15, #51, and #68) reviewed for abuse and neglect. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. […]

• Immediate jeopardy, patternF609Mar 28, 2025

  Based on interview and record review the facility failed to ensure that all alleged violations involving verbal, sexual, physical,and/or mental abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse in accordance with State law through established procedures, for 3 (#6, # 15, and #51) of 3 (#6, # 15, #51) residents reviewed for abuse. […]

• Immediate jeopardy, patternF610Mar 28, 2025

  Based on interview and record review the facility failed to ensure allegations of verbal, physical, and/or mental abuse, were thoroughly investigated for 3 (Resident #6, Resident # 15, and Resident #51) of 3 (Resident #6, Resident # 15, and Resident #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. […]

• Immediate jeopardy, patternF835Mar 28, 2025

  Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Resident #6, Resident # 15, Resident #25, Resident #51, and Resident #68) of 34 Sampled Residents. The facility failed to: 1. Protect and ensure Resident #15 was free from verbal abuse and psychosocial harm by S4 CNA; 2. Ensure Resident #51 and Resident #6 were free from resident to resident physical abuse by Resident #25; 3. Ensure Resident #68 was free from neglect by S6 CNA; 4. […]

• No harm, potential for more than minimal, patternF679Mar 26, 2026

  Based on observation, interview, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities based on comprehensive assessments, care plans and preferences for 3 (Resident #15, Resident #43, and Resident #70) of 33 sampled residents. This deficient practice has the potential to affect all 83 residents currently residing in the facility. Findings:Review of the facility's undated policy titled, Activities , read in part . The facility will provide an ongoing program of actives that support the interest and enhances the quality of life of each resident. Activities will be individualized based in resident assessments, preferences, and functional abilities. Procedure: 3. […]