Accolade Healthcare of Peoria

In the surveyor’s words

From the most serious findings on record at Accolade Healthcare of Peoria, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 15, 2023

  Based on observation, interview, and record review the facility failed to implement appropriate fall interventions for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 obtaining bilateral black eyes, fracturing her right nasal bone, and knocking out two natural teeth. Findings include: The facility's Fall Prevention Program, revised 1/21, documents to provide ongoing risk reducing interventions. This form also documents to provide ongoing evaluation of resident response to intervention. On 6/14/23 at 10:30am, R1 was in her wheelchair in activities. R1 had black yellowish bruising on her bilateral cheek bones. R1 also had a healing laceration under her [NAME]. […]

• Actual harm, isolatedF689Apr 18, 2023

  Based on observation, record review and interview, the facility failed to utilize a mechanical lift to transfer a resident (R2) and failed to utilize a gait belt and ensure surfaces were dry when transferring a resident in the shower room (R1), for two of three residents (R1, R2) reviewed for falls in a sample of three. This failure resulted in R2 falling on 2/09/23 and sustaining a fracture of the right tibia and fibula, when V3 (Certified Nursing Assistant) attempted to pivot transfer R1 from the bed to the wheelchair. This past non-compliance, which involved R2, occurred from 2/09/23 to 3/16/23. Findings include: The facility policy, titled Transfers (revised 1/2020), documents Purpose: To provide guidelines to nursing assistant/nurse for proper technique for transferring residents. […]

• Actual harm, isolatedF689Feb 9, 2022

  Based on interview and record review, the facility failed to have fall mat interventions in place from a prior fall for one (R1) of three residents reviewed for falls in a sample of three. This failure resulted in R1 obtaining a subdural hematoma, and a forehead laceration with three sutures. Findings include: Facility Policy: Falls, dated July 2021, documents Falls are a major cause of injury. Older adults are at risk for falls. The purpose of this guideline is to describe strategies that can identify individuals at risk for falls and develop interventions that are individualized to each resident. Reassessing fall risk and fall prevention programs will ensure a proactive approach to reducing falls. […]

• Actual harm, isolatedF684Nov 30, 2021

  Based on interview and record review the facility staff failed to recognize and take immediate action for a critical change in a resident's condition by failing to act promptly upon a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in a delay of treatment, resulting in R3 being hospitalized in critical condition. FINDINGS INCLUDE: The facility Assessment Tool completed 07/13/21 documents, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs as well as your capabilities to provide services to the residents of your facility. Part 2. […]

• No harm, potential for more than minimal, widespreadF921Feb 19, 2026

  Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment. This has the potential to affect all 132 residents living in the facility.Findings include:R36's MDS/Minimum Data Set, dated [DATE], documents R36's diagnoses include Alzheimer's Dementia, is severely impaired for cognition, uses a manual wheelchair, and dependent for cares. R36's current care plan documents R36 is a high risk for falls. R50's MDS, dated [DATE], documents R50's diagnoses include Non-Alzheimer's Dementia, is severely impaired for cognition, uses a wheelchair, and is dependent for care. R50's current care plan documents R50 is a high risk for falls. […]