Accolade Healthcare of Savoy

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide all items noted on the daily menu and ensure availability of substitutions for residents of the facility. This has the potential to affect all 182 residents residing at the facility.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure meals were palatable, attractive, and appetizing for residents. This failure has the potential to affect all 182 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate beverages to residents. This failure has the potential to affect all 182 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to keep equipment functioning properly to ensure the kitchen was maintained in a manner to prevent food born illness. This failure has the potential to affect all 182 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean and homelike environment for one of three (R2) residents reviewed for environment in a sample of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with meals to one of three (R1) residents reviewed for activities of daily living in a sample of six.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the mechanical soft diet consistency per resident needs for three of three (R1, R3 and R6) residents reviewed for mechanical soft diet in a sample of six.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure dependent residents were provided dignified care, this failure affected two (R1 and R8) of eight residents reviewed for hygiene/dignity on the sample list of nine residents.

Inspectors wroteBased on observations, interviews and record review, the facility repeatedly failed to maintain a safe environment for residents at risk of falls. These failures affected two residents (R2, R8) of six residents, which were reviewed for falls/environment, on the sample list of nine residents. With fall prevention interventions not being followed for R2 and R8. 1. R2's current Diagnoses List documents the following: Diabetes Mellitus Type II, With Hyperglycemia, Diabetes Mellitus Type II, With Polyneuropathy (damage nerves, causing numbness, tingling and weakness), Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Difficulty Walking, Not Elsewhere Classified. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental status (BIMS) score as 12 out of a possible 15, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care in a timely manner for one (R2) of eight residents reviewed for incontinence care/activities of daily living on the sample list of nine residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 193 residents residing in the facility.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, ranges for control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 193 residents in the facility. B. Based on observation, interview, and record review the facility failed to maintain appropriate handwashing during incontinent care for one of four residents (R92) reviewed for infection control in a sample of 62.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to maintain call lights accessible for resident use. This failure affects five of five residents (R1, R2, R11, R64, R97) reviewed for call lights on the sample list of 62. B. Based on observation, interview, and record review, the facility failed to ensure an electric bed remained consistently functional to maintain a resident's toileting independence. This failure affects one resident (R155) of ten reviewed for accommodation of needs in the sample list of 62. Findings Include: A. The facility's Call Lights policy dated January 2026 documents when a resident is in bed or in a chair, staff are to ensure the call light is within easy reach of the resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and implement interventions to prevent accidents. These failures affect three of eight residents (R124, R133, R148) reviewed for accidents and supervision on the sample list of 62. Findings Include: 1. R133's Medical Diagnoses Sheet date March 2026 documents R133 is diagnosed with Dysphagia, Hemiplegia, and Vascular Dementia. R133's Physician Order Sheet dated March 2026 documents a regular mechanical soft diet order. R133's Minimum Data Set, dated [DATE] documents R133 is cognitively intact and coughs or chokes during meals or when swallowing medications and has complaints of difficulty or pain with swallowing. R133's Care Plan dated 2/27/26 documents R133 has a swallowing problem related to a diagnosis of Dysphagia. R133 is at risk for Choking and Aspiration. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications according to physician's orders for three of 11 residents (R51, R116 and R187) reviewed for medication administration on the sample of 62 residents. The facility had three errors out of 27 opportunities resulting in a medication error rate of 10.71 percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin pens were dated when opened and medications were discarded when discontinued. This failure affects four of four residents (R222, R47, R21, R89) reviewed for medication storage in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain and provide timely and dignified quality of care. This failure affects two of three residents (R1, R155) reviewed for dignity on the sample list of 62. Findings Include: The facility's Resident Rights for People in Long Term Care policy dated November 2018 documents residents in long term care facilities have the right to be treated with dignity and respect. The facility must provide services to keep each resident's physical and mental health at their highest practical levels. 1. On 3/1/26 at 11:42 AM R1 was in her room in her wheelchair. The room smelled of feces and R1 stated she was soiled and needed to be changed. R1 stated she had been waiting a long time for staff to come and change her. R1 appeared upset and kept repeating that she just needed help and wanted to be cleaned up. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was completed upon discharge from the facility for one (R105) of four residents reviewed for resident assessments on the sample list of 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise a resident's care plan for suprapubic catheter care. This failure affects one (R27) of 35 residents reviewed for care plans on the sample list of 62.

Inspectors wroteBased on interview and record review, the facility failed to provide timely assistance for incontinence cares for one resident (R106) of five reviewed for Activities of Daily Living (ADLs) in the sample list of 62 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hydration to one of two residents (R133) reviewed for hydration on the sample list of 62. Findings Include: The Hydration and Prevention of Dehydration policy dated January 2026 documents the facility will provide adequate hydration. Nurse Aides will provide and encourage intake of bedside and meal fluids on a daily basis. R133's Medical Diagnoses Sheet dated March 2026 documents R133 is diagnosed with Dysphagia, Diabetes, Chronic Kidney Disease Stage Four and Vascular Dementia. R133's Dehydration Risk dated 2/21/26 documents R133 is at risk related to Dementia, Diabetes, Antipsychotic Medications, and Incontinence. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and administer an influenza vaccine to ensure a resident was up to date for vaccines for one (R11) of five residents reviewed for immunizations on the sample list of 62.

Inspectors wroteBased on interview and record review the facility failed to timely report daily weight changes for congestive heart failure to the physician for one of three residents (R3) reviewed for changes in condition in the sample list of nine. This failure resulted in R3 admitting to the intensive care unit for acute on chronic respiratory and heart failure requiring intravenous diuresis related to fluid retention.

Inspectors wroteBased on interview and record review the facility repeatedly failed to notify the Physician of one (R1) resident's elevated glucose levels out of three residents reviewed for Quality of Care in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility repeatedly failed to administer one (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.

Inspectors wroteBased on observation, interview and record review the facility failed to check the placement of one (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.

Inspectors wroteBased on observation, interview and record review the facility failed to follow Infection Control Procedures for one (R3) resident on Enhanced Barrier Precautions (EBP) out of five residents reviewed for medication administration in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to monitor and report changes in condition, including monitoring and reporting blood pressures, daily weights, and urination for two of five residents (R1, R2) reviewed for changes in condition in the sample list of nine. These failures resulted in a delay in treatment for R1's changes in condition, R1 was hospitalized with congestive hyponatremia (low sodium), acute kidney injury (AKI), renal failure, urinary tract infection (UTI), and required dialysis. The facility's Physician Notification of Resident Change of Condition policy dated [DATE] documents the Director of Nursing (DON) is responsible for monitoring the 24-hour report to ensure physicians are notified of changes in condition. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to use foot pedals during wheelchair transportation for two of four residents (R3, R4) reviewed for accidents in the sample list of nine residents. This failure resulted in R3's right leg contacting the floor causing ankle fractures. The facility also failed to supervise a cognitively impaired resident (R7) at risk for elopement, which resulted in R7 leaving the facility's property unnoticed. R7 was one of three residents reviewed for elopement in a sample list of nine. 1.) On 8/27/25 at 9:30 AM, R3 was sitting in her wheelchair in her room. R3's right leg was in a splint and elevated on the wheelchair leg rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records are complete and accurate for four of seven residents (R1, R2, R3, R7) reviewed for changes in condition and elopement in the sample list of nine. The facility's Content of the Medical Record policy dated August 2017 documents the Administrator is responsible for ensuring medical records are maintained according to regulations and guidelines. This policy documents medical records should include documentation of resident care, observations, assessments and changes in condition. This policy documents physician and consultant visits should be recorded at the time of each visit. 1.) R1's 8/13/25 and 8/19/25 Provider Progress Notes with print date 9/2/25 were provided by V2 Director of Nursing (DON) on 9/2/25. These visit notes were not uploaded into R1's Electronic Medical Record (EMR). [...]

Inspectors wroteBased on Interview, Observation and Record Review the facility failed to notify the physician and power of attorney for an incident of elopement for one (R7) of three residents reviewed for elopement on a sample list of nine. On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse (LPN) stated V10 did not complete an assessment, notify R7's physician or family, and didn't follow the Facilities Missing Resident Policy for R7's elopement from the facility on 8/31/25. On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident. Video surveillance was viewed with V1 at this time. [...]

Inspectors wroteBased on interview and record review the facility failed to transcribe physician's orders for one of four residents (R3) reviewed for accidents in the sample list of nine. On 8/27/25 at 9:30 AM, R3 was sitting in her wheelchair in her room. R3's right leg was in a splint and elevated on the wheelchair leg rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. R3 stated R3 had difficulty holding her legs up, R3's right foot went underneath of R3 causing R3's ankle to roll or twist and R3 screamed out in pain. R3 stated R3 has two broken ankle bones because of that incident. [...]

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one of five residents (R2) reviewed for changes in condition in the sample list of nine. R2's hospital discharge orders dated 7/22/24 include orders for Metoprolol Succinate (cardiac medication) Extended Release 12.5 milligrams (mg) by mouth (PO) daily, Midodrine (treats low blood pressure)10 mg PO three times daily, and Novolog insulin per blood glucose-based sliding scale three times daily before meals. R2's July 2025 Medication Administration Record documents R2's Metoprolol, Midodrine, and Novolog insulin were stopped on 7/23/25 and R2 did not receive any doses of these medications after the morning dose on 7/23/25 prior to being hospitalized on the evening of 7/24/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to privacy. This failure affects one resident (R1) of three reviewed for privacy in the sample of six. This past non-compliance occurred from 7/10/2025 to 7/16/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a resident fall to the licensed nurse, directly resulting in a lack notification of the residents physician and family member. This failure affects one resident (R1) out of one reviewed for notifications on the sample list of six. This past compliance occurred from 6/20/25 and 7/1/25.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to report a resident fall to the licensed nurse, directly resulting in a lack of a licensed nurse completing a nursing assessment and a neurological assessment prior to picking the resident up from the floor. This failure affects one resident (R1) out of one reviewed for fall reporting on the sample list of six. This past compliance occurred from 6/20/25 and 7/1/25.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident right to be free from verbal abuse (R3) by another resident (R2) and failed to protect a resident right to be from physical abuse (R3) by another resident (R2). R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnosis; Spastic Quadriplegic Cerebral Palsy, Seizures, Quadriplegia, Obstructive Sleep Apnea, Anxiety Disorder, Hyperlipidemia, Deficiency of Specified B Group Vitamins, Schizophrenia, Esophagitis without Bleeding, GERD, Insomnia, Functional Quadriplegia, HTN, Depression, Retention of Urine and Personal History of Malignant Neoplasm of Testis. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 6, severe cognitive impairment and is dependent on staff's assistance with Activities of Daily Living. [...]

Inspectors wroteBased on interview and record review the facility failed to report an injury of an unknown origin to the state survey agency for one (R6) of three residents reviewed for injuries in the sample list of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for one (R1) of three residents reviewed for pressure ulcers in the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to timely report post fall pain and implement radiology orders timely, resulting in a delay in treatment of a left hip fracture for one (R4) of three residents reviewed for falls in the sample list of eight.

Inspectors wroteBased on observation, interview and record review the facility failed to provide bathing, oral care, and toileting for three (R1, R2, and R4) of four residents reviewed for dependent activities of daily living from a total sample list of four.

Inspectors wroteBased on observation, interview and record review the facility failed to identify, assess, make the appropriate notifications, obtain treatments and interventions for three pressure wounds for one (R1) of four residents reviewed for pressure wounds from a total sample list of four residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately encode Minimum Data Sets to reflect resident status with regards to falls experienced and severity of injuries incurred. This failure affects three residents (R1, R2, R4) out of four reviewed for falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to obtain weights per physician orders for two residents (R89, R96) and failed to adequately monitor an at risk resident for weight loss, failed to obtain weekly weights, failed to notify the resident's representative of weight loss, and failed to develop a plan of care to address severe weight loss for one resident (R154). These failures affected three of ten residents (R89, R96, R154) reviewed for nutrition on the sample list of 82. These failures resulted in continued severe weight loss for R154. Findings Include: The facility's Weight policy dated March 2023 documents weekly weights will be done with a significant change of condition, food intake declines for more than one week, or with a physician order. [...]

Inspectors wrote- Based on an interview and record review, the facility failed to communicate regularly with the dialysis center to coordinate care and failed to monitor a dialysis central venous catheter access site for one resident (R22). This failure resulted in R22's hospitalization with a central venous catheter infection. R22 is one of two residents reviewed for dialysis on the sample list of 82.

Inspectors wroteBased on observations, interviews, and record reviews, the facility repeatedly failed to implement fall interventions for R1, R2, and R3 and repeatedly failed to complete R2's quarterly fall risk assessments. These failures affected three of the three residents (R1, R2, and R3) reviewed for falls on the sample list of seven.

Inspectors wrote-- Based on record review and interview, the facility failed to notify a resident's family representative of positive laboratory test results for an infectious disease and failed to notify both the family representative and a physician/nurse practitioner of a significant decline in a resident's level of consciousness, abnormal lung assessment, and a productive cough. This failure affected one of four residents (R4) who were reviewed for changes in condition on the sample list of seven.

Inspectors wroteBased on record review and interviews, the facility repeatedly failed to maintain complete and accurate resident medical record, by failing to document the application of a physician ordered back brace. This failure affected one of seven residents (R1) reviewed for complete medical records, on the sample list of seven.

Inspectors wroteBased on record review and interview the facility failed to provide pain management by not having the correct pain medication available for R1 upon admission to the facility. This failure resulted in R1 experiencing severe pain from R1's recent joint replacement surgery when pain medication was not available. R1 is one of three residents reviewed for pain management in a sample of three. This past compliance occurred from 9/26/24 to 9/27/24.

Inspectors wroteBased on the interview and record review, the facility failed to properly transfer one of two residents (R1) reviewed for peripherally inserted central catheter (PICC) maintenance on the sample list of three. This past noncompliance occurred from 8/29/24 through 9/7/24. Findings Include: The facility's PICC/Central Venous Catheter Dressing Changes policy, dated 9/1/23, states that PICC/Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Transparent semi-permeable dressings are changed every seven days or as needed. R1's Minimum Data Set, dated [DATE] documents that R1 is cognitively intact. R1's Medical Diagnoses Sheet, dated September 2024, documents that R1 is diagnosed with Osteomyelitis. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain residents' dignity by failing to answer call lights and respond to requests for assistance in a timely manner. This failure affects eight residents (R1, R2, R6, R8, R9, R20, R21, and R23) out of 17 reviewed for call light response times on the sample of 35.

Inspectors wroteBased on observation and interview, the facility failed to maintain flooring in resident bathrooms in a clean, safe, and homelike manner. This failure affects 15 residents (R7, R8, R12, R22, and R25 through R35) out of 23 reviewed for environmental concerns on the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of mental abuse to the state agency in the 2 hour required timeframe. This failure affects one resident (R1) out of twelve reviewed for abuse on the sample of 35.

Inspectors wroteBased on record review and interviews the facility failed to protect two residents from misappropriation of property by facility staff. This failure caused R1 to have 11 transactions totaling $1515.96 being misappropriated from R1's private bank account. This failure affects two (R1, R2) residents on the sample list of three reviewed for misappropriation of personal property.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from misappropriation of property by failing to follow the facility's Abuse Prevention Program by staff taking photographs of residents (R1, R2) personal property and sharing the photographs with another person. R1 and R2 are two residents reviewed for abuse in the sample list of three. Findings Include: The facility's Abuse Prevention Program dated 10/20/2022 documents the facility affirms the right of it's residents to be free from misappropriation of property. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belonging or money without the resident's consent. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were in place, safely position a resident on a low air loss mattress, keep necessary items within reach for a resident, and store a rolling chair away from resident areas. The facility also failed to complete post fall assessments, transfer a resident post fall according to facility policy, and thoroughly investigate falls. These failures affect three of three residents (R1, R4, R5) reviewed for falls on the sample list of seven.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident right to dignified care and treatment. This failure affects one of three residents (R3) reviewed for dignity/abuse on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a residents' right to be free from verbal/mental abuse by another resident. This failure affects two of three residents (R1 and R2) reviewed for abuse on the sample list of three.

Inspectors wroteBased on record review and interview the facility failed to ensure an allegation of physical and verbal abuse by R2 towards R1, was reported to the Administrator/Abuse Prevention Coordinator. This failure resulted in R1 and R2 continuing to reside in the same bedroom, potentially subjecting R1 to further abuse by R2. R1 and R2 are two of three residents reviewed for abuse on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to ensure two staff were assisting during a mechanical lift transfer for one of four residents (R2) reviewed for falls on the sample list of four. This past noncompliance occurred from 4/20/24 to 4/25/24.

Inspectors wroteBased on interview and record review the facility failed notify the physician of a resident refusal of catheterization for one (R1) of three residents reviewed for physician notification on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to administer narcotic medications safely to one (R1) of three residents reviewed for narcotic administration on the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to revise and update a resident's (R1) Plan of Care to include Gastrostomy Residual Volume checks before each enteral feeding. R1 is one of three residents reviewed for Care Plans in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to have physician orders in place regarding Gastrostomy Residual Volumes (GRV) check with result parameters prior to starting tube feedings for three (R1, R2, R3) of three residents reviewed for tube feedings in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policies to accurately record and account for controlled medications for 28 of 28 residents (R1, R2, R3, R9-R33) reviewed for controlled medications in the sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one of four residents (R6) reviewed for injuries in the sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to administer medications in accordance with physician's orders for two of five residents (R5 and R9) reviewed for medications in the sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to complete performance reviews to identify training needs and provide training for CNAs (Certified Nursing Assistants). This failure has the potential to affect all 158 residents who reside in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) documents 158 residents reside at the facility. The Facility's Assessment tool dated December/2022 through November/2023 states Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours every year. Include dementia management training and resident abuse training. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure all Certified Nurse's Aide's (CNA) received twelve hours of annual training including required subjects. This failure has the potential to affect all 158 residents residing in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) documents 158 residents reside at the facility. The Facility's Assessment tool dated December/2022 through November/2023 states Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours every year. Include dementia management training and resident abuse training. [...]

Inspectors wroteBased on interview and record review the facility failed to assess the need for psychotropic medication upon admission and quarterly for four of five (R73, R63, R134, R80) residents reviewed for psychotropic medications on the sample list of 77.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of undated insulin for seven (R104, R51, R68, R1, R134, R119, R64) of seven residents reviewed for medication storage from a total sample list of 77 residents.

Inspectors wroteBased on interview and record review the facility failed to provide Advance Beneficiary Notices (ABN) to three of three residents (R264, R146, and R6) reviewed for Beneficiary Protection Notifications on the sample list of 77.

Inspectors wroteBased on observation, interview and record review the facility failed to provide nail care to one of 31 residents (R56) reviewed for Activities of Daily Living in the sample list of 77.

Inspectors wroteBased on interview and record review the facility failed to have fall prevention interventions in place on admission for one of two residents (R215) reviewed for falls in the sample list of 77.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene before or after administering medications and obtaining a blood glucose level for five (R52, R119, R64, R415 and R156) of five residents reviewed for medication administration on the sample list of 77.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the worsening of a resident's facility acquired pressure ulcers. The facility failed to implement pressure ulcer care plan interventions and prevent cross contamination during pressure ulcer wound care for a resident (R3). These failures affect one (R3) residents of three residents reviewed for pressure ulcers in a sample list of nine residents. These failures resulted in R3's Stage III pressure ulcer worsening and development of two additional necrotic pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of residents. This failure affects two (R3, R4) out of three residents reviewed for Activities of Daily Living in a sample list of nine residents.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident (R2) who had previously been placed on continual monitoring was monitored resulting in R2's fall. This failure affects one (R2) resident out of three residents reviewed for accidents in a sample list of nine residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete pressure ulcer risk assessments for (R3), monitor and assess pressure ulcers for (R3), document skin assessments as ordered for (R3) and implement pressure relieving interventions for (R1 and R3). R1 and R3 are two of three residents reviewed for pressure ulcers in the sample list of 88.

Inspectors wroteBased on observation, interview, and record review the facility failed repeatedly to ensure gastrostomy tube (G-tube) feeding volumes were administered as ordered for (R2 and R3), failed to record the amount of feeding administered for (R2 and R3), and failed to verify gastrostomy tube placement prior to administering feeding and medications for (R1). These failures affect three of three residents (R1, R2, and R3) reviewed for gastrostomy tubes on the sample list of 88.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain resident bedroom, bathroom and shower room call lights in operable condition on the second floor of the facility. This failure affects 84 of 84 residents (R1-R3, and R8-R88) reviewed for call lights on the sample list of 88.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's Family Member and provide a written Notice of Transfer and Discharge from the facility, when being discharged to the hospital. This failure affects one of three residents (R1) reviewed for discharge from the facility. This past non-compliance occurred from 8/15/23 to 9/1/23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure ulcer risk assessments, wound assessments, and wound physician progress notes were part of the electronic medical record for one of five residents (R3) reviewed for pressure ulcers in the sample list of 88.