Savoy Care Center

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure administration of narcotics were properly documented on the narcotic record for 2 (Cart A & Cart B) of 2 medication carts reviewed during the medication storage facility task.

Inspectors wroteBased on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #59 & Resident #60) of 33 sampled residents, by failing to:1. Promote resident dignity by providing a bedpan per the resident request for Resident #60.2. Promote resident dignity by providing disposable dishware for Resident #59 in the dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received a reasonable accommodation of their needs by failing to ensure the call light was accessible to a resident for 1 (Resident #3) of 33 sampled residents. Review of a facility policy dated 01/16/2026, titled Answering the Call Light revealed in part. The purpose of this procedure is to respond to the residents needs and request. 5. When the resident is in bed or confined to a chair be sure the call light is within easy each of the resident. Review of Resident #3's medical record revealed an admission date of 12/07/2023, with diagnoses that included, in part, Moneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease. Review of Resident #3's Quarterly MDS with an ARD 03/03/2026 revealed Resident #3 had a BIMS of 6, indicating severe cognitive impairment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #84) of 33 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive plan of care was reviewed and revised to include nursing interventions implemented for a client with behaviors that required increased supervision and monitoring of behaviors for 1 resident (Resident #61) of 33 sampled residents.

Inspectors wroteBased on record review and interview the facility failed to obtain laboratory services as ordered by a physician to meet the needs of its residents for 1 (#2) of 5 (#1, #2, #7,#10, and #11 ) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record, the facility failed to ensure that the mattress was compatible with the bedframe for 1 (Resident #3) of 33 sampled residents. Review of Resident #3's medical record revealed an admission date of 12/07/2023, with diagnoses that included, in part, Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease. Review of Resident #3's Quarterly MDS with ARD 03/03/2026 revealed Resident #3 had a BIMS of 6, indicating severe cognitive impairment. On 03/23/2026 at 11:39 a.m., observation revealed Resident #3 lying in bed with his feet hanging off of his mattress. Resident #3's mattress appeared to be too small for the bed frame. On 03/24/2026 at 10:12 a.m., an observation revealed Resident #3 lying in bed, positioned on his back with his head elevated. The resident's air mattress was observed not to fit the bed frame properly. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure:1. A fall mat was in place as ordered and care planned for Resident #1, and2. Physician's orders for increasing water flush for Resident #3, who received feeding and hydration via PEG (Percutaneous Endoscopic Gastrostomy), was followed.

Inspectors wroteBased on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a resident's Medical Director was notified of Registered Dietician recommendation in a timely manner for 1 (#2) of 6 (#1, #2,#3, #4,#5, and #6) sampled residents.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. This deficient practice resulted in an Immediate Jeopardy situation on 02/16/2025, when S4 CNA yelled and cursed Resident #15, and made her go to bed; on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies; and on 03/08/2025 at approximately 4:20 p.m., when Resident #25 pulled Resident #6's hair. [...]

Inspectors wroteBased 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. Resident #51 stated this made her mad. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff, in Hall X dining room, provided water to 10 residents with their meal during lunchtime.

Inspectors wroteBased 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. Have an effective system in place to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made for Resident #6, Resident # 15, and Resident #51; and 5. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate) code status.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review) Level I and/or Level II for 1(#23) resident of 2(#23 and #26) residents reviewed for PASARR screening.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan to meet the needs of 3 ( #34, #36, and #37) residents of 34 sampled residents. The facility failed to ensure Resident #34's and Resident #36's fall interventions were implemented, and failed to ensure 2 person physical assistance was used for bed mobility and toileting for Resident #37.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (#68) of 1 resident reviewed for pressure ulcers. The facility failed to ensure: 1. gloves used during wound care were not contaminated by the bedside table; and 2. gloves were removed and hands were sanitized after cleaning Resident #68's wound.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to administer a resident's enteral flush per the physician orders for 1(Resident #68) of 1 residents investigated for enteral feedings.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#47) of 1 residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assure the accurate administering of all drugs to meet the needs of each resident by failing to maintain accurate and complete documentation of controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of needs for 1 (#3) of 2 (#2 and #3) sampled residents reviewed for call bell placement. The facility failed to ensure Resident #3 had a call bell in reach in order to call for assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent incidents and accidents. The facility failed to ensure a resident wore a smoker's apron to prevent accidents while smoking for 1 (Resident #17) of 1 residents reviewed for smoking.

Inspectors wroteBased on interview and record review the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments for 1 (#3) of 7 (#1, 2, 3, 4, 5, 6, and 7) sampled residents. The facility failed to ensure Resident #3 who had an iodine allergy was not served and consumed a meal tray that contained shellfish.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1 (#6) of 1 residents observed for wound care.

Inspectors wroteBased on record review, and interview the facility failed to ensure a residents received treatment and care in accordance with professional standards of practice, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to: 1. Ensure that medication was prescribed by a physician prior to being administered; and 2. Ensure Resident #1 received medications as ordered by the physician.