Accolade Healthcare of Pontiac

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 20, 2021

  Based on observation, interview and record review, the facility failed to ensure R1, at risk for elopement (leaving the facility unnoticed), received supervision to prevent R1 from leaving the facility alone and unnoticed. This failure resulted in R1 exiting the facility alone and undetected by staff during the pre-dawn hours on 7/5/21. R1 was found by the local police department a half a mile away from the facility on the ground in a residential neighborhood with bruising and swelling above R1's right eye. R1's injuries included an Acute Subarachnoid Hemorrhage, an Acute Right-sided Orbital Floor Blowout Fracture with Inferior Displacement and Prolapse of Orbital Fat, Right Maxillary [MEDICATION(S)] and Nasomaxillary Fractures, Large Right Pre-septal and Periorbital Soft Tissue Hematoma. […]

• Actual harm, isolatedF689Jun 17, 2026

  Based on observation, interview and record review the facility failed to use foot pedals when transporting a resident in a wheelchair and failed to follow a care plan intervention to utilize a mechanical lift to transfer a resident for two (R2 and R7) of three residents reviewed for accidents in the sample of eight residents. These failures resulted in R2 falling from the wheelchair and suffering a head laceration requiring sutures and R7 suffering a fractured rib when staff transferred R7 without using the mechanical lift. Findings Include:1. […]

• Actual harm, isolatedF689Mar 12, 2026

  Based on record review and interview the facility failed to ensure safe transfer techniques were implemented for one (R1) of three residents reviewed for accidents. The resident sustained a fracture of the left knee when a mechanical lift transfer requiring two staff members was performed by only one staff member.Findings Include The Facilities Hydraulic Lift (Hoyer) Policy revised on 1/26 documents all nursing staff will be trained on the proper use of the hydraulic (hoyer) lifts that are used within the facility, to ensure safe transfer for residents. This Policy also documents that the staff is to obtain assistance from a second staff member.On 11/29/26 at 3:04AM, the Nursing Progress notes documents: R1was sent to the hospital after complaining of pain in the area above her left knee. […]

• Actual harm, isolatedF692Aug 23, 2024

  Based on observation, interview, and record review the facility failed to implement an ordered nutritional supplement and failed to notify a resident representative of the significant weight loss for one of two residents (R379) reviewed for nutrition in the sample list of 26. These failures resulted in R1's severe weight loss of 10.8% in 12 days. Finding include: On 8/20/2024 at 11:55 AM, R379 was sitting in a wheelchair in the dining room eating lunch with V17 (family) present. No nutritional supplements were present on the tray. At this time, V17 states R379 has lost a lot of weight since his surgery, which was prior to being admitted to the facility. […]

• No harm, potential for more than minimal, widespreadF812Aug 23, 2024

  Based on observation, interview and record review the facility failed to maintain the facility kitchen food service areas, and equipment in a clean, sanitary condition to prevent potential cross-contamination and food-borne illness to residents. This failure has the potential to affect all 76 residents residing in the facility. Findings include: On 08/20/24 at 9:50 am, during the initial tour of the facility kitchen, accompanied by V7, Dietary Manager (DM), the commercial table mounted can opener had a build-up of a grease-like substance in the gears. Adhering to the grease-like substance were metal fragments, and rust. The commercial can opener also had the silver laminate missing from the bottom inch of the blade. […]