Accolade HC of Paxton on Pells

In the surveyor’s words

From the most serious findings on record at Accolade HC of Paxton on Pells, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 27, 2025

  Based 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. […]

• Actual harm, isolatedF699Aug 27, 2025

  Based 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.Findings include:R1's progress note documents R1 was admitted to the facility from home on 7/17/25 at 3:09PM. R1's physician's note dated 7/1/25 documents R1 is a candidate for assisted living. […]

• Actual harm, isolatedF686Jan 16, 2025

  Based 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. Findings include: On 1/13/25 at 9:15AM, 12:38 PM, 1:46 PM and 2:05 PM R70 was sitting in a wheelchair in R70's room. R70 was in her wheelchair in the assisted dining room from 11:50 AM until 12:23PM. At 2:08 PM V12 and V13 Certified Nursing Assistants (CNA) entered R70's room with a full mechanical lift and transferred R70 into bed. […]

• Actual harm, isolatedF689Oct 10, 2024

  Based 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. Findings include: 1.) R2's Admission Minimum Data Set (MDS) dated [DATE] documents R2 admitted to the facility on [DATE]. R2 had moderate cognitive impairment, was always incontinent of bowel and bladder, and required dependence on staff for toileting, moving from sitting to standing, and with chair/bed transfers. R2's Nursing Notes document R2 expired on [DATE]. […]

• Actual harm, isolatedF689Jul 1, 2024

  Based 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. Finding include: R1's hospital records dated 6/15/24 document R1 was sent to the emergency room due to a fall. This record documents, (R1) was being repositioned and rolled out of bed at nursing home. (R1) has obvious signs of head trauma. […]