Accolade Hc of Paxton on Pells

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall interventions and thoroughly investigate falls for two of three residents (R1, R2) reviewed for falls in the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to maintain documentation of neurological assessments for one of three residents reviewed (R1) for falls in the sample list of three.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen equipment in clean, sanitary, operable condition to prevent cross contamination, maintain freezer temperatures and ensure pureed food is a safe consistency. These failures have the potential to affect all 93 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain residents right to dignified care, for two of two residents (R10 and R13) reviewed for activity of daily living assistance/dignity, on the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident for two of four residents (R75 and R84) reviewed for abuse on the sample list of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to protect a resident's right to be free from sexual abuse by another resident. This failure affects two of four residents (R5 R4) reviewed for abuse on the sample list of five. This past non-compliance occurred from 10/17/25 to 10/17/25. Findings Include: The Minimum Data Set, dated [DATE] documents R4 is cognitively intact. The Minimum Data Set, dated [DATE] documents R5 is cognitively impaired. Nursing Progress Notes dated 10/17/2025, document R4 was seen with his hand underneath R5's shirt. The Notes document the Abuse Coordinator, Power of Attorney and the Medical Director were notified. On 11/25/25 at 8:25AM, V5 (Licensed Practical Nurse) stated he was the nurse that day on 10/17/25 when R4 touched R5. V5 stated he was going down the hall by the dining room and saw R4's hand underneath R5's shirt. [...]

Inspectors wroteBased on interview and record review the facility failed to establish clear communication regarding notification to a funeral home to remove a resident R1 remains for 1 of 3 residents reviewed for death. This past non-compliance occurred from [DATE] to [DATE].

Inspectors wroteBased on interview and record review the facility failed to prevent elopement of a resident when staff did not verify that the exit door was properly secured after use. This failure effected one (R1) of three residents reviewed for elopement.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly and accurately assess and measure pressure wounds at least weekly for two residents (R2, R3) of three residents in a sample list of nine residents. This failure caused (R2, R3) to experience worsening of facility acquired pressure ulcers. Findings Include:1. R3's Current diagnoses list includes the following diagnoses: Hearing Loss, Anxiety, Muscle Wasting and Atrophy, Difficulty Walking, Depression, Pressure Ulcer Left Buttock, and History of Lumbar Spinal Fusion. R3's wound assessment dated [DATE] by V7, Licensed Practical Nurse (LPN) Wound nurse documents R3 has a Stage 3 Facility Acquired Pressure Ulcer first identified on 7/2/25. There are no wound assessments or measurements observed documented prior to 7/8/25. [...]

Inspectors wroteBased on interview and record review the facility failed to identify potential triggers for Post Traumatic Stress Disorder (PTSD) and failed to initiate resident centered interventions to address PTSD for one resident (R1) admitted to the facility with a diagnosis of PTSD of three residents reviewed for admission transfer discharge rights in a sample list of nine residents. Consequently, R1 experienced an exacerbation of behavioral symptoms leading to emergent hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions, complete pressure ulcer and skin assessments, and notify the physician of new pressure ulcers to obtain treatment orders for one of four residents (R70) reviewed for pressure ulcers in the sample list of 38. These failures resulted in R70 developing two stage two and one stage three pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This failure has the potential to affect all 92 residents within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to assure that menus and menu substitutions are developed, prepared, and followed to meet residents' therapeutic diets and nutritional needs while using established national guidelines. This failure affects one of four residents (R70) reviewed for nutrition and has the potential to affect all 92 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This failure has the potential to affect all 92 residents in facility.

Inspectors wrote5. On 01/13/25 at 09:20 AM, R39 had an EBP (Enhanced Barrier Precautions) sign posted outside of R39's room but there was no PPE (Personal Protective Equipment) cart at R39's door. At this time, R39 stated staff wear gloves but not gowns when providing cares to R39. On 1/14/25 at 08:40 AM, R39 was lying in bed with a urinary catheter in place. The EBP sign remained posted outside of R39's room. At this time, R39 stated R39 had been told by V30 LPN (Licensed Practical Nurse) that his urine was cloudy but then a couple weeks later, R39 ended up being hospitalized with a UTI (Urinary Tract Infection). On 1/15/25 at 9:08 AM, V30 LPN stated R39 has a history of UTI's and confirmed that V30 had noticed R39's urine was cloudy, prior to R39 being hospitalized with a UTI. [...]

Inspectors wroteBased on interview and record review the facility failed to have a qualified Infection Preventionist with the required training in infection prevention and control. This failure has the potential to affect all 92 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for four of four residents (R39, R17, R25 and R52) reviewed for hospitalizations on the sample list of 38. Findings Include: 1. R39's ongoing Census documents R39 was hospitalized from [DATE] - 7/24/24 and 12/30/24 - 1/2/25. R39's medical record does not contain a copy of the facility Bed Hold Policy. On 01/14/25 at 8:40 AM, R39 stated R39 went to the hospital recently but unsure of the exact date. R39 stated the facility did not talk with him about a Bed Hold Policy. On 1/14/25 at 12:21 pm, V2 DON (Director of Nursing) stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy is sent with the resident, and we keep a copy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain privacy during wound care for one (R70) of 24 residents reviewed for privacy in the sample of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to offer services to maintain or increase range of motion for one of three residents (R34) reviewed for range of motion in the sample list of 38.

Inspectors wroteBased on interview and record review the facility failed to investigate and record a fall incident and failed to complete fall risk assessments for one of one resident (R39) reviewed for falls on the sample list of 38.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform hand hygiene before and after catheter care to prevent potential contamination and failed to ensure a urinary drainage bag was covered with a dignity bag for one of one resident (R39) reviewed for catheters on the sample list of 38. Findings Include: On 1/13/25 at 8:40 am and 3:12 PM, R39 was lying in bed and had an uncovered urinary catheter drainage bag hanging on the bed frame, which was visible from the hallway. On 1/14/25 at 8:40 am, R39 was lying in bed and had an uncovered urinary catheter drainage bag hanging on the bed frame, which was visible from the hallway. On 1/15/25 at 11:25 AM, R39 was lying in bed and the urinary catheter drainage bag was hanging on the bed frame, covered in a dignity bag. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain a re-admission weight, notify the physician and resident representative of significant weight loss, and develop a plan of care to address significant weight loss for one of three residents (R77) reviewed for weight loss on the sample list of 38. Findings Include: The facility's Weight Management policy dated August 2017 documents all residents will be weighed on admission, re-admission, and weekly for the first four weeks, then monthly thereafter. Weekly weights will also be done with a significant change of condition. Any significant weight loss will be reviewed with the physician to obtain an order for a nutritional supplement until the resident's condition is discussed during weekly risk meetings. The resident's care plan will be updated to include interventions promoting weight gain or loss. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain hygienic care and storage of continuous positive airway pressure (CPAP) masks and oxygen nasal cannulas, and failed to develop a care plan for respiratory care and diagnosis for two of three residents (R57, R34) reviewed for oxygen in the sample list of 38.

Inspectors wroteBased on interview and record review the facility failed to ensure that as needed psychotropic medication was limited to 14 days for one of five residents (R49) reviewed for unnecessary medications on the sample list of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement fall interventions and safety measures, provide effective supervision to prevent a fall, and thoroughly investigate falls for two (R2, R3) of three residents reviewed for falls in the sample list of four. These failures resulted in R2 sustaining two falls with head lacerations that required suture and staple closure.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of potential sexual abuse to the Abuse Coordinator and to the State Surveying Agency. This failure has the potential to affect two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings Include: The untitled facility investigation dated 8/28/24 documents in the morning meeting on 8/28/24 at approximately 10:15 AM it was mentioned that R2 was found in R1's bed the night before. V1 Administrator had not been made aware of the incident until that moment. An investigation began and staff were interviewed. V4 Certified Nursing Assistant (CNA) stated she worked the evening before (8/27/24) and witnessed R2 on top of the covers in R1's bed kissing R1 on the cheek. V4 stated she called down the hall for V5 Licensed Practical Nurse (LPN) to come and assist. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a fall by failing to explain cares and ensure safety while elevating a bed for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 falling from the bed to the floor and sustaining a skull fracture with a brain bleed.

Inspectors wroteBased on interview and record review the facility failed to re-evaluate and coordinate discharge plans to address the needs of a resident (R1) being discharged home and notify the physician of changes in the discharge plan for one of three residents reviewed for discharge in the sample list of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct and thoroughly document weekly skin assessments, identify a newly reopened pressure ulcer, notify the physician, and obtain pressure ulcer treatment orders for one (R4) of three residents reviewed for pressure ulcers in the sample list of six.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the resident representative and physician of significant weight loss, update a care plan with interventions to address/prevent weight loss for (R11) and implement nutritional recommendations for three (R11, R40, R4) of four residents reviewed for nutrition in the sample list of 50. This failure resulted in R11 experiencing a severe weight loss of 12.01 % in six months.

Inspectors wroteBased on observation, interview, and record review the facility failed to post staffing data which included staffing hours and the facility census. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 90 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have necessary sanitation test equipment and failed to effectively sanitize dishes. These failures have the potential to affect all 90 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable environment by failing to provide warm showers. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to promote dignity while dining for four (R11, R22, R7, R23) of 24 residents reviewed for dignity in the sample list of 50. B. Based on interview and record review, the facility failed to provide timely assistance to residents when answering call lights. This failure affects five residents (R2, R45, R56, R68, and R76) of 50 reviewed for resident rights on the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance for fingernail care, toenail care, shaving, and timely assistance for toileting/incontinence cares for four (R69, R81, R76, R21) of five residents reviewed for Activities of Daily Living (ADLs) in the sample list of 50 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications timely as ordered and in accordance with manufacturer's instructions for three (R7, R31, R39) of 11 residents reviewed for medication administration in the sample list of 50. This failure resulted in six medication errors out of 25 opportunities, a 24% medication error rate.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for self-administration of medication for one (R6) of one resident reviewed for self-administration of medications in the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the risk of urinary tract infections by failing to prevent the back flow of urine while providing catheter care for one (R40) of three residents reviewed for catheter care on the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician orders for the administration of oxygen, change and label oxygen tubing and humidifier bottles for (R28). (R28) is one of one resident reviewed for oxygen in the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to give pain medication prior to a pressure ulcer treatment for one (R40) of two residents reviewed for pain on the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt alternatives prior to the use of bed rails for one (R27) of one residents reviewed for bed rails on the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the need for emotional support after the loss of roommates (R42, R202, R203) for one (R8) of 24 residents reviewed for environment on the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication labels were legible, label eye drops with opened dates, and ensure medications were not used after expiration. This failure affects three (R39, R48, R148) of 13 residents reviewed for medication storage in the sample list of 50 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food in the consistency and texture that is prescribed for one (R11) of four residents reviewed for nutrition in the sample list of 50.

Inspectors wroteBased on interview and record review the facility failed to offer and administer pneumococcal vaccines to ensure residents are up to date for two (R80, R40) of five residents reviewed for immunizations in the sample list of 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to regularly inspect bed rails and ensure the bed rails were secured to the bed for one (R27) of one residents reviewed for bed rails on the sample list of 50.

Inspectors wroteBased on interview and record review the facility staff failed to provide safe transfer for one resident (R1) when using the mechanical lift for transfer. This failure resulted in R1 sustaining a non-displaced fracture to the Right Humerus. (R1) is one of four residents reviewed for accidents in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation into an allegation of misappropriation of property for five of eight residents (R1, R3, R8, R9, R10 and R11) reviewed for misappropriation of property on the sample list of 11. Findings Include: The facility's Reporting/Investigating Resident Abuse Policy dated April 2019 documents any individual who has reason to believe that physical abuse, mistreatment, or neglect has occurred must immediately notify the Administrator. An investigation will be initiated immediately by the Administrator/Designee. The investigation shall consist of, where possible and appropriate: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of resident property to the resident representative for two of eight residents (R1, R11) reviewed for misappropriation of property on the sample list of 11. Findings Include: The facility's untitled Abuse Prevention Policy dated 10/3/21 documents residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent. If mistreatment has occurred, the resident's representative and Department of Public Health shall be informed as soon as possible of any allegations of abuse. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall prevention interventions for one of three residents (R2) reviewed for falls in the sample of three. Findings Include: The facility's Fall Prevention Program dated October 2023 documents the policy is in place to provide guidelines on preventing resident falls or injury. The same policy documents staff should assess residents for fall risk and initiate risk reducing interventions. R2's undated Medical Diagnoses List documents R2 is diagnosed with Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the Right Side, Lack of Coordination, Reduced Mobility, and Muscle Weakness. R2's December 2023 Physician Order Sheet documents R2 is prescribed Eliquis (Anticoagulant) 5 milligrams twice daily for Atrial Fibrillation. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to timely report a resident fall to the resident's representative and physician for one (R1) of four residents reviewed for falls in the sample list of four. This failure resulted in R1 experiencing uncontrolled pain and a delay in treatment for R1's left hip fracture following a fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete post fall neurological assessments, complete post fall assessments/monitoring, identify a change in condition, and properly transfer a resident (R1) following a fall. These failures affect three (R1, R2, R3) of four residents reviewed for falls in the sample list of four. These failures resulted in R1 experiencing uncontrolled pain and a delay in treatment of R1's left hip fracture following a fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to document a fall in the resident medical record and failed to prevent resident falls by failing to thoroughly investigate falls and implement fall interventions. These failures affect three (R2, R3, R4) of four residents reviewed for falls in the sample list of four. These failures resulted in R2 falling and sustaining a dislocated right ring finger.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate pain and manage pain for one (R1) of four residents reviewed for falls in the sample list of four.