Health inspection·April 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 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. Residents Affected - Few Findings include: The facility's Acute Condition Changes - Clinical Protocol dated June 2023 documents the nurse should assess, document and report changes in pain level. Nursing staff will contact the physician based on the urgency of the situation and the physician will be paged/called requesting prompt response, approximately one half hour or less, for emergencies. This policy documents the nursing staff and the physician will discuss possible causes including resident history and symptoms, and the physician will order diagnostic testing or directly evaluate the resident if necessary. This policy documents the physician will review the status of the condition change and document the evaluation, including the significance of the acute change, at the next visit. R4's admission Minimum Data Set, dated [DATE] documents R4 is cognitively intact and R4 had no pain during the review period. R4's Nursing Note dated 4/1/2025 at 6:05 AM documents at 2:35 AM R4 was heard yelling out and R4 was found on the floor near the doorway of his room. R4 reported R4 was trying to go to the bathroom, got weak and fell to the floor. R4 had a bruise and abrasion to the left knee, bruise to left arm, and denied pain. R4 had upper and lower extremity range of motion. The on-call physician, V27, was notified. R4's Physical Therapy (PT) Encounter Note dated 4/2/25 at 12:06 PM, recorded by V28 PT Assistant, documents R4 was only able to tolerate sitting on the edge of the bed for two minutes due to increased left lower extremity pain from recent fall. R4 refused to stand or transfer into the wheelchair and tolerated the session poorly secondary to increased left lower extremity pain. R4's Occupational Therapy (OT) Encounter Note dated 4/1/25 at 2:46 PM, recorded by V13 Certified OT Assistant (COTA), documents R4 complained of hip pain related to a fall this morning and was waiting on an x-ray. V13 spoke with the nurse who reported R4 fell at 2:30 AM and there were no x-ray orders since R4 had not complained of pain. R4 was encouraged to try and sit on the edge of the bed, but refused. R4's therapy participation was limited due to lack of motivation and recent fall. R4's OT Encounter Note dated 4/2/25 at 2:44 PM, recorded by V13, documents R4 continues to complain of hip pain from fall. R4 reported not taking pain medications since no one had asked. V13 spoke with the nurse about pain medications and getting an x-ray since R4 refused to get out of bed until x-ray (continued on next page) 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 Page 1 of 3 Event ID: 145439 Printed: 05/15/2026 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 145439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2025 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)