Inspection·September 3, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. This policy documents when there is a change in resident condition, the nurse must assess the resident, document the change in the resident's medical record, notify the resident's physician, and place the resident on the 24-hour report to ensure close monitoring of the condition on each shift.1.) R1's hospital Discharge summary dated [DATE] documents R1 was hospitalized for cystitis with hematuria, AKI, Acute on chronic respiratory failure, Pneumonia, Myocardial Infarction, Severe Sepsis, Pulmonary Edema, elevated B-Type Natriuretic Peptide, UTI and Acute Heart Failure. R1's Blood Urea Nitrogen (BUN) was 47 and Creatinine (Cr) was 1.8 on [DATE]. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and required supervision/touch assistance from staff for toileting hygiene and partial/moderate staff assistance for toilet transfers. R1's Care Plan dated [DATE] documents R1 receives diuretic therapy, monitor for side effects and effectiveness, observe/document/report adverse reactions including postural hypotension, report lab results to the physician, especially Sodium and Potassium. R1's [DATE] Medication Administration Record (MAR) documents R1's daily weight (pounds) as 144.9 on [DATE], 145 on [DATE], 148.8 on [DATE], 150.2 on [DATE], 149 on [DATE] and 149.6 on [DATE]; and to notify of three-pound gain in 24 hours or five-pound gain in one week. This MAR documents R1 received the following medications: Amlodipine 10 milligrams (mg) one tablet by mouth (PO) daily 8/13-[DATE] when changed to half a tablet daily. Lasix 20 mg PO daily, Isosorbide Mononitrate Extended Release (ER) 120 mg PO daily, Lisinopril 20 mg PO daily and Metoprolol Succinate ER 50 mg twice daily [DATE]-[DATE]. R1's Physician Orders dated [DATE] document to notify if no urinary output for eight hours, and reporting parameters for systolic blood pressure less than 100.R1's Urinary Continence report dated [DATE]-[DATE] documents R1 as continent/incontinent once on [DATE], [DATE], [DATE], [DATE], and twice on [DATE], [DATE], and [DATE]. This report does not document the number of times R1 urinated or the amount. R1's blood pressure log documents R1's blood pressures as follows:[DATE] at 4:02 PM 90/43 [DATE] at 5:21 PM 90 / 42 [DATE] at 4:24 PM 79 / 29 [DATE] at 2:52 PM 95 / 47 [DATE] at 7:36 AM 89 / 34 [DATE] at 11:04 PM 91 / 35 [DATE] at 11:10 PM [DATE]/2025 at 8:34 PM 91 / 39 [DATE] at 1:25 AM 149 / 49 [DATE] at 7:31 PM 138 / 71R1's Progress Note dated [DATE], recorded by V21 Nurse Practitioner, documents to continue daily weight and will recheck Basic Metabolic Panel (BMP). There is no documentation that a BMP was collected prior to [DATE]. The Coverage On-Call Note dated [DATE] at 10:29 PM documents nurse contacted V20 Nurse Practitioner to report that R1 reports she had not urinated for two days, and R1 had been eating/drinking well with fluids encouraged. This note documents V21 ordered Urinalysis with culture and sensitivity this morning, but the nurse did not think this was completed. This note documents to straight catheterize to obtain urine sample and if greater than 300 cubic centimeter of urine return then leave the catheter inserted. R1's Progress Note dated [DATE], recorded by V21, documents R1 reported having minimal urine output for the last couple of days, R1's BUN was 76 and Cr was 6.2 on [DATE], will send R1 to the emergency room for further evaluation and treatment. R1's Nursing Notes document the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 2 of 13 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 09/03/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few following: -[DATE] at 7:36 AM R1 reported scanty urine overnight and was concerned she may be developing UTI. A request for straight catheterization and urinalysis was sent via electronic facsimile to V28 Physician. -[DATE] at 6:47 AM R1's urinalysis/culture and sensitivity order note, will collect on Sunday shift for lab to pick up Monday morning. [DATE] at 7:39 PM due to lab schedule, will collect tomorrow. [DATE] at 12:24 AM due to lab schedule, collect tomorrow.- [DATE] at 1:40 PM R1 urinated twice this shift and had removed the collection hat from the toilet, and the second time urine sample obtained by clean catch, but was contaminated with bowel movement. Urine sample to be collected and picked up on Monday. - [DATE] at 10:05 PM R1 voided in collection hat, but urine was contaminated with bowel movement. R1 also voided in the shower, but was unable to collect sample. R1 was unable to void again at this time. -[DATE] at 5:20 AM R1 had minimal urine in collection hat, missed hat. -[DATE] at 1:13 PM Unable to obtain R1's urine sample. -[DATE] at 10:17 PM R1's urine was collected via straight catheterization and placed in the fridge for lab pick up.-[DATE] at 1:21 PM V21 Nurse Practitioner reported R1 is being sent to the hospital due to critical lab results, acute kidney injury, low output, and increased confusion.R1's Care Plan Conference Note dated [DATE] document R1 and V23, R1's Family, voiced concerns regarding urine output and fluids; and V23 reported this to the floor nurse. R1's medical record does not document that R1's urine output and urine characteristics were routinely monitored every shift between [DATE] and [DATE], that R1's low blood pressures were reported prior to [DATE], or that R1's weight gain was reported to a provider. There is no documentation in R1's nursing notes that a provider was notified of unsuccessful attempts to obtain R1's clean catch urine sample or urinalysis and culture results prior to [DATE]. R1's urine culture dated [DATE] documents Candida Albicans (fungus) 70-99,000 colony forming units per milliliter (cfu/ml).R1's hospital emergency room note dated [DATE] documents R1 reports for the last couple days she has had diarrhea which started yesterday, increased back pain and concern for possible UTI with painful urination and frequency. This note documents R1 as alert and oriented to person, place and time, and R1 had coarse rhonchorous lung sounds. R1's laboratory results showed [NAME] Blood Cell 14.07 (normal 4-11), B-Type Natriuretic Peptide 1785 (normal 0-100), BUN 85 (normal 10-20), Chloride 87 (normal 98-107), Cr 6.51 (normal 0.55-1.02), and Sodium (NA) 115 (normal 136-145). R1's chest x-ray documents patchy bilateral infiltrates, which are stable and noted on prior x-ray, may be related to congestive heart failure. R1's urine culture dated [DATE] documents greater than 100,000 cfu/ml of Nakaseomyces glabrata and Candida Albicans (bacteria.) R1 was admitted to the intensive care unit (ICU) with diagnosis of hyponatremia (low sodium), acute kidney injury, hypoxia (low oxygenation), renal failure, and hypochloremia (low chloride). R1's ICU note dated [DATE] documents R1 received IV fluids, IV antibiotics, and had low urine output. R1 had AKI on CKD likely prerenal from diarrhea and volume contraction and likely the cause of hypovolemia and hyponatremia, R1's baseline Cr is around 2.25 and baseline NA is 133-139. R1's AKI on CKD is likely acute tubular necrosis (kidney damage leading to AKI or renal failure) and R1 has possible Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (body produces too much ADH causing water retention and hyponatremia). Lasix was held due to signs of hyponatremia and may need continuous renal replacement therapy (dialysis) if diuresis remains inadequate. R1's ICU Note dated [DATE] documents R1 started dialysis and was intubated due to worsening oxygen requirement. R1's Death Summary documents R1 expired on [DATE] at the hospital after almost 10 days of intubation with worsening shortness of breath and continued dialysis through today, family opted for comfort measures. On [DATE] at 3:48 PM, V23 (R1's Family) stated R1 had pneumonia and UTI prior to readmitting to the facility, and the staff should have been monitoring R1's urination and labs. V23 stated R1 had reported back pain and lack of urination to her, which had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 3 of 13 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 09/03/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few reported to unidentified nurses on day four, but R1 went seven days before anything was done. V23 stated by that time, R1 had developed low sodium levels and kidney problems, and was hospitalized . V23 stated R1 was placed on a ventilator and is actively dying.On [DATE] at 11:31 AM, V8 Licensed Practical Nurse (LPN) stated R1 initially admitted to the facility for about 16 hours and was sent to the hospital for a heart attack and sepsis. V8 stated R1 returned from the hospital and was sent out again due to lab work and concerns about kidney function. V8 stated it started out that we needed to get a urine sample on V8's shift and a collection hat was placed in R1's toilet. V8 stated we couldn't get the urine sample because it was contaminated with bowel movement and the second time R1's roommate had removed the hat. V8 stated R1 wanted to use the toilet rather than trying to straight catheterize her, so we let her. V8 stated R1's lab results came back before her urine results. V8 stated lab does not collect on the weekend, we have to have someone drop the sample off at the lab, and we would have straight catheterized R1 if we wouldn't have gotten the sample by Monday for the lab to pick up on Tuesday. On [DATE] at 3:08 PM, V7 Certified Nursing Assistant (CNA) stated V7 took care of R1 one time and R1 complained of back pain, which was reported to the nurse. V7 stated urine output measurements are recorded for catheters, otherwise it is charted once per shift if the resident was incontinent or continent. On [DATE] at 3:21 PM, V6 Registered Nurse stated V6 sent R1 to the hospital as ordered by V21 for critical labs and concern for kidney issues on [DATE]. V6 stated R1 urinated that day and twice on her shift on [DATE] but was unsure of the amount. V6 stated we were checking R1's urine because R1 thought she had a UTI, R1 toileted herself at times and we attempted to get a clean catch specimen in the hat, but it was contaminated with bowel movement. V6 was unsure if V6 notified the provider of unsuccessful attempts to obtain R1's urine sample. V6 stated provider notification would be documented in the nursing notes. On [DATE] at 10:09 AM, V16 Licensed Practical Nurse (LPN) stated staff tried to obtain R1's urine sample, but R1 kept having bowel movements in the collection hat. V16 stated R1's urine was being tested because R1 had complained of scanty urination, per the nursing notes. V16 stated on 8/16 or [DATE] V23 told V16 R1 had not urinated, but then V23 took R1 to the bathroom and R1 urinated, so V23 told V16 not to worry about it. V16 stated V16 encouraged R1 to drink cranberry juice and water, and refilled R1's water pitcher multiple times. V16 stated R1 drank the fluids at mealtimes too. V16 stated V16 was urinating but was unsure of the amount. V16 stated a urine sample can't' be collected too early which would cause lab to deny it on Monday's pick up. V16 confirmed V16 did not attempt to straight catheterize R1 prior to [DATE], when the sample was obtained and sent to lab. V16 stated only clean catch attempts were made since R1 was able to use the bathroom, and straight catheterization is used for residents who are incontinent. V16 confirmed R1 had low blood pressure and thought V16 reported this to the provider, which would be documented in a nursing note. On [DATE] at 11:25 AM, V2 Director of Nursing (DON) stated the providers specify if a straight catheterization or clean catch is needed, and clean catch is attempted if the resident is able to urinate on their own. V25 Assistant DON stated we have a standing order to straight catheterize if we are unable to obtain a clean catch sample within 24-48 hours. V2 stated lab only collects samples on the weekends if it is for STAT (immediate) orders, otherwise lab collects on Monday. V25 stated the nursing staff should call the on-call nurse manager to drop off a specimen on the weekends. V25 confirmed R1's urine culture was completed on [DATE]. V2 reviewed R1's daily weights and confirmed R1's weight gain noted between [DATE] and [DATE] and confirmed provider notification if greater than three pounds in one day or five pounds in a week. V2 stated strict intake, and output is only recorded if the resident has a catheter, otherwise it is documented in a progress note or as needed in the CNA tasks as incontinent/continent not the number of times or amount. V2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 4 of 13 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 09/03/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few stated if it isn't recorded in the tasks, then that doesn't mean that the resident did not urinate. V25 provided R1's provider notes and communication notes and confirmed [DATE] was the only notification of R1's low blood pressures. At 11:58 AM, V2 confirmed there was no documentation that a provider was notified of R1's weight gain. On [DATE] at 8:45 AM, V21 stated R1's low blood pressures were reported to V21 on [DATE] and R1's Amlodipine was decreased to 5 mg and parameters given for blood pressure medications. V21 reviewed R1's recorded blood pressures and stated R1's blood pressures should have been reported sooner and V21 would have made adjustments in R1's medications sooner and added blood pressure parameters for blood pressure medications. V21 stated the facility contacted V20 Nurse Practitioner on [DATE] and confirmed the order to obtain urine via straight catheter and leave in catheter if greater than 300 ml of urine return. V21 stated V20 communicated this to V21. V21 stated V21 evaluated R1 on [DATE] and ordered BMP and CBC, which V21 scheduled for [DATE] since R1 had labs on [DATE]. V21 stated daily weights should be monitored and reported if gain of three pounds in one day or five pounds in a week. V21 reviewed R1's daily weights and confirmed R1's weight gain was not reported. V21 stated if this was reported, V21 would have ordered a one-time additional dose of Lasix based on R1's [DATE] BMP. V21 confirmed the staff should have been monitoring R1's urine output after R1's complaints on [DATE]. V21 stated staff should notify the provider if it has been eight hours without urination and staff should have straight catheterized R1 on [DATE]. V21 stated this delay in treatment could lead to complicated UTI, decreased urine output, and AKI. V21 stated if V21 was made aware of these changes in R1's condition sooner, V21 probably would have sent R1 out to the hospital sooner due to needing fluids and diuresis on top of having congestive heart failure and renal disease. V21 reviewed R1's [DATE] urine culture and stated V21 would have treated this as a UTI since R1 was symptomatic. sent her out to the hospital sooner due to needing fluids on top of having CHF. Reviewed R1's urine culture results from facility [DATE], stated she would have treated it as a UTI since she was symptomatic. V21 stated decreased blood pressure and decreased urine output along with days without reporting could have contributed to R1's [DATE] lab results, and R1 could have been sent out sooner and may not have required dialysis. V21 stated R1 was very sick and had a lot of things going on, so it is hard to say if these failures and delay in treatment caused R1's death, it may have only prolonged things if R1 had received hospital treatment sooner. On [DATE] at 10:27AM, V20 stated V20 verbally gave R1's orders listed on [DATE] to the facility nurse. V20 stated the facility does not have a nurse manager on the weekends to remove the orders from (electronic health record software) so the orders aren't followed up on until Monday. 2.) R2's Progress Note dated [DATE], recorded by V20, documents post hospital evaluation for R2 who was hospitalized 6/13-[DATE] for congestive heart failure exacerbation, sepsis, pneumonia, orthostatic hypotension; and hospitalized 7/16-[DATE] for worsening anemia. upper gastrointestinal bleed from duodenal ulcer, weakness, and shortness of breath. This note documents R1's weight is up 10-15 pounds, suspect fluid overload from hospital hydration and blood administration, if BMP is stable on [DATE] will consider increasing Lasix over several days if weight remains elevated, continue to monitor vitals and weight daily. R2's Progress Note dated [DATE], recorded by V30 Physician, documents the same findings as V20 noted above and to monitor weight and vital signs daily. R2's [DATE] Medication Administration Record (MAR) documents to obtain daily weights and report weight gain of three pounds in 24 hours or five pounds in one week, but there is no documentation this order was resumed after R2 readmitted from the hospital on [DATE]. This MAR documents to obtain vital signs every shift, but the last recorded vitals are on dayshift on [DATE].R2's weight log documents R2's readmission weight as 160.4 on [DATE] and 175.8 on [DATE]. There are no recorded weights after [DATE].R2's blood pressure log does not document R2's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 5 of 13 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 09/03/2025 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete blood pressure was obtained after dayshift on [DATE] prior to R2's hospitalization on evening shift on [DATE]. On [DATE] at 10:00 AM, V25 Assistant Director of Nursing (ADON) confirmed R2 did not have daily weights resumed after [DATE] and no vital signs documented after dayshift on [DATE]. V25 stated V25 thought R2 was still in the hospital on [DATE] and therefor discontinued some of his orders. V25 stated we are pushing for the providers to enter their orders into the resident's electronic medical record (EMR) so that it requires the nurse to sign off and activate the orders. V2 and V25 confirmed physician and nurse practitioner progress notes are not consistently uploaded into the resident's EMR, these notes have to be pulled from (electronic health record software), which the floor nurses do not have access to. On [DATE] at 10:27 AM, V20 stated per facility policy, vital signs should be monitored at least twice daily, and staff should have been monitoring R2's vitals and daily weights. V2 stated R2 had a history of edema and shortness of breath with prior hospitalization. V20 stated the protocol for daily weight monitoring is to report a three-pound gain in one day or five-pound gain in one month. Event ID: Facility ID: 145439 If continuation sheet Page 6 of 13 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 09/03/2025 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)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. 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. R3 stated R3 had right knee replacement surgery on 7/23/25, V29 (Podiatrist) applied R3's leg splint yesterday and told R3 that she could either choose to have surgery or go four to six weeks non-weight bearing without surgery. R3 stated R3 has a follow up orthopedic appointment next week to determine if there was any damage to R3's right knee. R3 stated R3 has not had any other falls or incidents that could have caused the injury. R3 stated R3 admitted to the facility for rehab and planned to return home, but now R3's recovery will take longer. R3's Minimum Data Set, dated [DATE] documents R3 as cognitively intact and has impaired range of motion to one lower extremity. R3's Care Plan active care plan documents R3 admitted to the facility following right knee arthroplasty (knee replacement), R3 has decreased functional ability and fatigue, and requires wheelchair for long distance transportation. R3's Incident Report dated 8/22/25 at 9:30 AM documents the following: R3 was assisted in wheelchair by staff while R3 was holding leg up with immobilizer in place. As R3 went over the threshold, R3 dropped her leg causing her foot to drop to the ground and R3 complained of pain after therapy. R3 reported that R3 thought she could make it to the therapy gym without wheelchair foot pedals, but by the time R3 made it to the threshold of the gym, R3 was too weak to hold her leg up causing her leg to drop. R3's right ankle portable x-ray dated 8/22/25 documents acute nondisplaced medial malleolus fracture of right ankle. R3's emergency room right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3's right knee was in immobilizer and without wheelchair foot pedals. R3 reported R3 was unable to hold her right leg up, her leg dropped and her foot/ankle bent underneath the wheelchair causing significant pain, [NAME], and bruising. R3's Progress Note dated 8/26/25, recorded by V29 Podiatrist, documents R3 was evaluated for right nondisplaced medial and lateral malleoli fractures. Treatment options were discussed and included fracture fragments are in anatomical alignment, given R3's age and limited ambulatory status related to knee replacement, conservative therapy would be an option, which would consist of four to six weeks of non-weight bearing followed by 4 weeks of weight-bearing in a boot prior to transitioning to ankle brace. Risk associated with this include continued instability of the ankle joint requiring of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 7 of 13 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 09/03/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few surgical intervention in the future and with R3's osteopenia, healing may take longer. Surgical intervention option would include fixation of the fractures to the right lower extremity, with weight-bearing pivot status approximately two weeks post-surgery, and full weight-bearing with boot for 4 weeks to transition back into an ankle brace. Associated risks include infection, pain, and need for additional surgery. R3 wanted to think about the treatment options before making a decision at this time. On 8/27/25 at 10:14 AM, V3 stated V3 was pushing R3 in a wheelchair down to the therapy gym, R3's right leg dropped as they crossed the threshold causing R3's ankle to turn. R3's right leg was in an immobilizer and there were no foot pedals on the wheelchair. V3 stated there were foot pedals in R3's room, but V3 did not apply them prior to transporting R3 to the gym. V3 confirmed the use of foot pedals would have prevented R3's leg from dropping. V3 stated the facility did an in-service and now everyone should have footrests on when being transported in a wheelchair by staff, and if they don't have footrests on, we are to ask the resident to self-propel their wheelchair rather than transporting them. On 8/27/25 at 2:05 PM, V2 Director or Nursing stated osteopenia is an underlying contributing factor, and V3 pushing R3 in a wheelchair without foot pedals, causing R3 to hold her legs up, caused R3's ankle fractures. V2 stated the facility does not have a policy regarding wheelchair transportation or use of foot pedals. V2 stated V2 expects foot pedals to be used whenever staff are pushing residents in a wheelchair long distances, otherwise the staff should have the resident self-propel their wheelchair. On 9/3/25 at 8:45 AM, V21 Nurse Practitioner stated on 8/22/25 R3 had ice on her ankle when V21 evaluated R3. R3 told V21 that her foot got caught underneath the wheelchair while staff transported her to therapy. V21 stated R3 did not have any complaints of ankle pain prior and had admitted post right knee replacement. V21 stated an x-ray was ordered and confirmed R3's ankle fractures. V21 stated it depends on the angle R3's foot/ankle got caught on whether this incident caused R3's fractures. V21 stated R3's right leg is weak due to post knee replacement, and staff should have used the footrests, which could have prevented R3's injury. 2.) On 8/27/25 at 9:23 AM, V13 Certified Occupational Therapy Assistant transported R4 in a wheelchair without foot pedals, down the hallway, past the nurses' station and into R4's room which was near the end of the hall. R4's feet were approximately two inches off of the floor. On 8/27/25 at 9:27 AM V13 stated R4 broke her clavicle from a fall prior to admitting to the facility and R4 is receiving physical and occupational therapy. V13 confirmed there were no foot pedals on R4's wheelchair and there should be. V28 stated V28 is going to have to get R4 foot pedals, and foot pedals should be used when transporting a resident in a wheelchair. On 8/27/25 at 9:49 AM R4 was lying in bed with a sling to her right arm. R4 stated R4 had fallen prior to admitting to the facility due to low blood sugar and broke her collar bone. R4 stated R4 doesn't have foot pedals on her wheelchair and R4 has to hold her feet up during transportation. There were no foot pedals in R4's room or on R4's wheelchair at this time. 3.) The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. Each Unit Charge Nurse, during their respective tour of duty will be aware and responsible for always knowing the location of their residents. Nursing must report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 8 of 13 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 09/03/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few and investigate all reports of missing residents. This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code “green” three times consecutively. Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility. The residents attending physician will be notified. This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated. Contact the resident's legal representative and inform him/her of the incident. Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator. On 9/2/25 at 11:08AM, R7 was wandering around the memory care unit walking up to the doors and windows and looking outside. On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse reenacted how R7 left the building through the door in the memory care unit. V10 stated that she had left to go to break around 8:55AM and when she returned around 9:08AM, V18 (R9's Family) had come into the facility and told V10 that V18 thought a resident was in the church parking lot. V10 stated V10 ran outside, R7 was in the church parking lot and V10 called V2 Director of Nursing to report the situation. V10 did not complete an assessment, notify the Medical Director or the Power Attorney and didn't follow the Facilities Missing Resident Policy regarding 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. On 8/31/25 at between 8:55 AM and 9:07 AM R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and green code was completed, as V1 is still investigating the failure. R7's minimum data set documented on 7/1/25 documents R7 is cognitively impaired. There is no documentation in R7's medical record that R7's elopement risk was reassessed after this incident or that new interventions were developed and implemented to address R7's elopement and exit seeking behavior. The last recorded Elopement Risk Assessment in R7's medical record is dated 7/6/25 and documents R7 as low risk. R7's active care plan documents the problem area elopement/risk wandering related to Dementia was not revised after R7's elopement until 9/3/25. On 9/2/2024 at 2:35pm, V2 Director of Nursing stated she received a call around 9:15am on 8/31/25 from V10 stating R7 had got out of the building and was next door in the church parking lot. On 9/3/2025 at 9:10AM, V21 (Nurse Practitioner) stated that there was no communication provided to any of the Physician On Call encounters from the facility about R7's elopement. V21 stated R7 has a history of Asthma, has a shuffled gait, and is at high risk for falling. V21 stated if V21 had been notified, she would have put in an intervention for increased monitoring or one to one supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 9 of 13 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 09/03/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based 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. R3's right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3's right knee was in immobilizer and without wheelchair foot pedals. R3 reported R3 was unable to hold her right leg up, her leg dropped, and her foot/ankle bent underneath the wheelchair causing significant pain, swelling, and bruising. R3's Progress Note dated 8/26/25, recorded by V29 Podiatrist, documents R3 was evaluated for right nondisplaced medial and lateral malleoli fractures, treatment options were discussed, including R3's osteopenia which may delay healing. This note documents an order for Vitamin D3 2000 units daily. R3's August and September 2025 Medication Administration Records document as of 8/6/25 R3 receives Os-Cal Calcium plus D3 500 milligrams (mg) - 5 micrograms (200 units of vitamin D3) one tablet by mouth daily and PreserVision multivitamin with minerals two tablets by mouth twice daily. As of 9/3/25, the order for Vitamin D3 2000 units had not been transcribed or implemented. On 9/3/25 at 10:00 AM, V2 Director of Nursing stated the facility does not receive any communication of new orders or progress notes after R3's orthopedic/podiatry appointments. V2 stated these progress notes have to be obtained from (electronic health records software). V2 confirmed R3's order for Vitamin D3 2000 units ordered on 8/26/25 by V29. V2 stated R3 receives a multivitamin and Os-cal, which provides less than 2000 units of Vitamin D3 daily. V2 stated V2 will implement the order today. Event ID: Facility ID: 145439 If continuation sheet Page 10 of 13 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 09/03/2025 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based 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. There is no documentation in R2's medical record as to why these medications were stopped or that the physician was notified of the missed doses. On 9/3/25 at 10:00 AM, V25 Assistant Director of Nursing stated on 7/23/25, V25 thought R2 was still in the hospital and did a batch order discontinuing R2's medications. V25 stated later that day V25 resumed R2's orders, but with batch orders not all of the orders pop up if they are too close to the next scheduled dose, so not all of R2's medication orders were resumed. V25 confirmed R2's missed doses of Midodrine, Metoprolol and Novolog insulin between 7/23/25 and 7/24/25. V25 stated these medications would be considered significant with missed doses as medication errors, but there was no negative impact on R2. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 11 of 13 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 09/03/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based 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). On 9/3/25 at 10:00 AM, V2 and V25 both confirmed provider progress notes are not consistently uploaded into each resident's EMR, including R1, R2, and R3. V2 stated these notes have to be pulled off of (electronic health record system), which the floor nurses do not have access to, only the nurse managers have access. 2.) R2's 7/11/25, 7/22/25 and 7/23/25 Provider Progress Notes with print date of 9/2/25 were provided by V2 on 9/2/25. These visit notes were not uploaded into R2's EMR. On 9/2/25 at 2:07 PM, V25 stated the providers enter notes in (electronic health record system) which the floor nurses do not have access to. V25 confirmed R2's Provider Progress Notes were obtained from (electronic health record system) and not included in R2's EMR. 3.) R3's 8/22/25 Provider Progress Note with print date 8/27/25, recorded by V21 Nurse Practitioner, documents at the time of visit R3 was sitting in a wheelchair with ice on her right ankle, and her ankle had mild swelling. This note documents R3 reported that R3's right leg was caught on the doorway causing R3 pain after this incident. V21 ordered an x-ray. This note was provided by V2 on 8/27/25 and was not uploaded into R3's EMR. R3's Incident Report dated 8/22/25 documents R3 was in a wheelchair propelled by staff. There were no foot pedals on R3's wheelchair. R3 was holding R3's leg up, which was in an immobilizer as R3's wheelchair crossed the threshold R3's leg dropped, and foot contacted the ground. This incident is not documented in R3's EMR. On 8/27/25 at 2:05 PM, V2 stated incidents are documented on an incident report which links to a nursing note in the resident's medical record. V2 confirmed R3's incident was not documented in R3's EMR. 4.) 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. On 8/31/25 between 8:55 AM and 9:07 AM, R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM, V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 12 of 13 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 09/03/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lot of the church. V1 stated that no notification to the medical director, power of attorney, and no green code was completed, as V1 is still investigating the failure. R7's 8/31/25 Nursing Progress notes documents R7 was exit seeking. There is no documentation in R7's medical record that R7 eloped from the facility on 8/31/25 or what steps were taken after R7's elopement and return to the facility. On 9/2/2025 at 12:37PM, V10 confirmed V10 did not follow the facility's missing resident policy and did not document R7's elopement incident in R7's medical record. On 9/2/2024 at 2:35pm, V2 (Director of Nursing) stated V2 received a call around 9:15AM on 8/31/25 from V10 stating R7 had left the building and was found next door in the church parking lot. V2 stated V2 told V10 to chart that R7 was exit seeking. The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. Each Unit Charge Nurse, during their respective tour of duty will be aware and responsible for always knowing the location of their residents. Nursing must report and investigate all reports of missing residents. This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code “green” three times consecutively. Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility. The residents attending physician will be notified. This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated. Contact the resident's legal representative and inform him/her of the incident. Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145439 If continuation sheet Page 13 of 13