Inspection·November 24, 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 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. Findings include:R3's Minimum Data Set, dated [DATE] documents R3 as cognitively intact. R3's active care plan revised 11/6/25, documents R3 has congestive heart failure (CHF) and includes an intervention for daily weight monitoring and to notify the physician with weight fluctuations as ordered. R3's November 2025 Medication Administration Record documents the following: R3 receives Torsemide (diuretic) 20 milligrams (mg) by mouth daily. No additional doses were given prior to a one time dose of 40 mg on 11/11/25. Obtain daily weight before breakfast and report gain of 3 pounds (lb) in 24 hours or 5 lbs in one week related to Congestive Heart Failure. R3 weighed 355 lbs on 11/1, 11/2, and 11/8. R3 weighed 394.6 lbs (39.6 lb gain) and 393.5 lbs. There is no documentation in R3's medical record that a provider was notified of R3's weight gain until 11/11/25 or that R3 was assessed/monitored for CHF symptoms such as edema after 11/9/25, besides routine vital signs and pulse oximetry (SPO2). R3's Situation Background Assessment and Recommendation (SBAR) Communication Form dated 11/11/25 at 3:36 PM documents R3 was lethargic (sluggish), pale, and sleeping on and off throughout the shift. R3 had edema (swelling) to both arms and left leg. R3 also had low Hemoglobin contributing to lethargy. These symptoms were reported to V15 Nurse Practitioner at 11:00 AM and new orders were given for an additional one time dose of Torsemide 40 mg for fluid retention. R3's Change in Condition note dated 11/11/25 at 3:26 PM documents V15 also gave orders to monitor vital signs every hour for the next four hours and apply R3's continuous positive airway pressure (CPAP) for oxygen therapy while resting in bed. R3's vitals were monitored and CPAP applied with no significant changes noted. R3's Nursing Note dated 11/11/25 at 5:38 PM documents V15 was updated on R3's change in condition and ordered for R3 to transfer to the hospital. R3's Intensive Care Unit (ICU) History & Physical Note dated 11/11/25 at 8:32 PM documents R3 presented to the emergency room for evaluation of progressive shortness of breath and over 35 lb weight gain over the past several days. R3 was found to be hypoxic with oxygen at 3 liters per nasal cannula and was placed on bilevel PAP. R3's chest x-ray showed pulmonary vascular congestion and R3 was given intravenous (IV) furosemide 40 mg in the emergency room and was admitted to the ICU for ongoing need for noninvasive ventilation and close monitoring and management of acute on chronic hypercapnic, hypoxemic respiratory failure. R3's assessment includes acute on chronic respiratory failure with diuresis treatment; and acute heart failure exacerbation with IV furosemide 40 mg three times daily, strict intake/output monitoring, and daily weights. On 11/21/25 at 9:27 AM R3 stated R3 just got back from the hospital and she was hospitalized due to retaining fluid. On 11/24/25 at 12:10 PM V3 Director of Nursing (DON) stated V3 thought the provider was notified of R3's Residents Affected - Few (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 2 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 11/24/2025 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)