Accolade Paxton Senior Living

In the surveyor’s words

From the most serious findings on record at Accolade Paxton Senior Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 16, 2022

  Failures at this level required more than one deficient practice statement: 1) Based on observation, interview and record review the facility failed to supervise R1, a resident with a known history of wandering and diagnoses of Dementia and Alzheimer's Disease with moderate cognitive impairment, which resulted in R1 leaving the facility alone and unsupervised. R1 was found by a member of the community, blocks away from the facility, unattended, seated in her wheelchair. R1 was self-propelling the wheelchair in the street of a residential neighborhood. R1 is one of three residents reviewed for wandering in the sample list of seven residents. […]

• Actual harm, isolatedF689Aug 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure safety of a resident by failing to ensure R1 was assessed for independent safe handling of extremely hot liquids. This resulted in R1 sustaining 2nd degree burns to R1's left thigh. The facility also failed to implement an intervention for an adaptive cup for one (R1) of three residents reviewed for accidents in the sample list of three. Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 has Dementia with moderate cognitive impairment and requires setup and supervision assistance for eating. R1's Care Plan dated 8/14/23 documents (R1) has a skin burn of the left lateral thigh/groin r/t (related to) burn from hot coffee spilled at dinner. […]

• Actual harm, isolatedF689Aug 3, 2022

  Based on observation, interview and record review the facility failed to complete a transfer for a resident according to the resident's plan of care for one of three residents (R2) reviewed for accidents in the sample list of three. This failure resulted in R2 sustaining a Right Humerus Fracture (an injury to the bone of the upper arm that connects the shoulder to the elbow).and R2 was admitted to the hospital. Findings include: The facility's Transfers policy with a revised date of 1/2020 documents, Purpose: To provide guidelines to nursing assistant/nurse for proper technique for transferring residents. Policy: To promote safe transfer for the residents, as well as the staff, gait belts, (mechanical lift), and/or sit to stand will be used, unless otherwise specified. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2024

  Based on observation, interview, and record review, the facility failed to monitor the dishwasher rinse temperatures to ensure sanitation of service wares and utensils utilized to serve meals to the residents. This failure affects nearly all (62 of 63) residents residing in the facility. Findings include: On 3/5/24 at 8:57 AM, V3, Dietary Manager, stated the commercial dishwasher utilized to wash the resident dishes, wares, and utensils, was a hot water sanitizing dishwasher. At this time, while the facility commercial dishwasher was in operation, the final rinse temperature was not displaying as designed on the digital display on the front of the dishwasher. […]

• No harm, potential for more than minimal, widespreadF725Aug 16, 2022

  Based on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants in accordance with their facility assessment. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The Facility assessment dated [DATE] documents the following: The facility's average daily census is 64. The facility's staffing plan includes a nurse to resident ratio of 1:23 for days and evenings, 3 nurses for days and evenings, and a certified staff to resident ratio of 1:11 for days and evenings, 6 certified staff per shift for days and evenings. The staffing plan also documents the facility is not always compliant with meeting these numbers due to staff hiring challenges and call-offs. […]