Accolade Paxton Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to ensure resident's call lights were answered in a reasonable time frame for seven of 17 residents (R50, R60, R81, R82, R74, R83, R43) reviewed for resident rights on a sample list of 43.B. Based on interview and record review the facility failed to ensure residents were treated with dignity and respect for three of 17 residents (R18, R74, R82) reviewed for resident rights in the sample list of 43. a.1) The facility policy Call Lights: Answering dated 8/2/17 documents call lights are to be answered in a reasonable time frame and all call lights should be answered courteously. Record review of Resident Council meeting minutes dated January, February, and March 2026 document ongoing concerns related to call lights not being answered timely. On 4/6/2026 at 12:15PM, V4 (R81's Power of Attorney) stated R81 had to wait an hour to get a Certified Nursing Assistant (CNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to appropriately label eye drops and inhalers with the date opened for three (R18, R42, R48) of eight residents reviewed for medication administration on a sample list of 43.Findings:On 4/8/26 at 10:53 a.m., the facility's Main Skilled Medication Cart was inspected in the presence of V20, Registered Nurse (RN). During the inspection, two open bottles of Latanoprost labeled for R18 were found without documented dates of opening. R42's Incruse Ellipta inhaler also lacked a documented date of opening and R48's Latanoprost and Timolol did not contain documented dates of opening.Review of R18's Medication Administration Record (MAR) dated April 2026 documents R18 has an active physician's order and is currently receiving Latanoprost 0.005 % Solution every evening.Review of R42's MAR dated April 2026 documents R42 has an active physician's order and is currently receiving Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 micrograms daily.Review of R48's MAR dated April 2026 documents R48 has an active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for two (R8 and R51) of 17 residents reviewed for advanced directives in the sample of 43. Findings Include: 1. R51's admission Record documents an admission date of [DATE]. R51's Order Detail Report printed [DATE] documents on [DATE] an Advance Directive order for Full Code. R51's Resident Information Sheet printed on [DATE] documents R51's Advance Directive as FULL CODE. R51's IDPH (Illinois Department of Public Health) Uniform Practitioner Order For Life-Sustaining Treatment (POLST) Form documented an X marked on the box for Do Not Attempt Resuscitation. This form was signed by R51 and dated [DATE] and signed by the Authorized Practitioner. R51's Care Plan revised on [DATE] documents R51 chooses to have death with dignity, advanced directive established. Individual wishes include: DNR refer to POLST. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to submit a discharge Minimum Data Sheet (MDS) resident assessment for two of 17 residents (R20, R54) reviewed for resident assessment on a sample list of 43.Findings Include: R20's census list documents an admission date of 11/12/25 and a discharge date of 12/27/25. R20's MDS list documents no discharge MDS completed. R54's census list documents an admission date of 11/06/25 and a discharge date of 12/11/25. R54's MDS list documents no discharge MDS completed. On 04/08/2026 at 11:22 AM V23 Minimum Data Set Registered Nurse stated she did in fact miss doing the discharge MDS for R20 and R54. V23 stated she usually completes the discharge MDS immediately.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise a care plan with falls and post fall interventions for one of three residents (R82) reviewed for falls in the sample list of 43. Findings include:On 4/6/26 at 9:37 AM R82 was lying in bed, bed was low to the floor, and a fall mat was beside the bed. R82 stated R82 recently admitted to the facility following shoulder surgery. R82 stated R82 slid out of her wheelchair two days ago. R82 stated R82 is using a different wheelchair than the one she was using that day. R82 stated R82 had a prior fall from her wheelchair while trying to stand up. R82 stated R82 was unsure what follow up actions the facility took to prevent further falls. R82's wheelchair contained an anti-tip device. The facility's Fall report dated 3/29/26 documents R82 fell at 10:30 PM after attempting to stand from her wheelchair to look for clothing in her closet. The interdisciplinary note dated 3/30/26 documents: R82's wheelchair brakes weren't locked at the time of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to accurately transcribe an order for pain medication for one of three residents (R18) reviewed for hospitalization in the sample list of 43. Findings include: On 04/06/2026 at 11:47 AM R18 stated he admitted to the facility from the hospital after being treated for severe pain in his left shoulder. R18 stated R18's pain returned and R18 was sent back to the hospital five days after R18 admitted to the facility. On 4/7/26 at 11:58 AM R18 showed a paper copy of R18's hospital discharge orders dated 3/9/26 which included Methocarbamol (muscle relaxant) 500 milligrams (mg) by mouth every six hours for 15 doses. R18 stated he did not recall taking this medication or requesting this order to be changed to as needed (PRN) instead of scheduled. R18's March 2026 Medication Administration Record (MAR) documents to administer Methocarbamol 500 mg by mouth every six hours as needed from 3/9/26-3/16/26, with only one dose administered. This MAR does not include the order to give Methocarbamol 500 mg every six hours for 15 doses. This MAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. When asked how the kitchen staff are monitoring the final rinse temperature to ensure the wares are being properly sanitized, V3 replied, I will have to look for test strips. V3 could not locate the temperature sensitive test strips. V3 questioned a Dietary Aid (V4) who likewise could not identify the location of the test strips. V4 also stated, I don't know how long the display has not been showing the final rinse temperature.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide dignity while obtaining a respiratory assessment for one (R46) resident out of one resident reviewed for dignity in a sample list of 33 residents. Findings include: R46's undated Medical Diagnosis List documents medical diagnoses of Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD), Protein Calorie Malnutrition, Shortness of Breath and Disorders of Electrolyte and Fluid Imbalance. R46's Minimum Data Set (MDS) dated [DATE] documents R46 as cognitively intact. R46's Care Plan intervention dated 11/20/2023 documents R46 transfers with the assist of one person and a walker. On 3/6/24 at 12:00 PM R46 was sitting at a dining room table eating the lunch meal. V14 Registered Respiratory Therapist (RRT) walked up to R46 while R46 was eating lunch meal and stated 'Put your finger out so I can get your Oxygen saturation (O2 sat)'. V14 RRT obtained R46's O2 sat, Pulse, Respirations and Blood Pressure at dining room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a Baseline Care Plan timely for one (R266) resident out of one resident reviewed for Baseline Care Plans in a sample list of 33 residents. Findings include: The facility policy titled '24 Hour Interim Care Plan' revised 2/2021 documents the purpose is to provide guidelines for completion of a 24 hour (Interim) Plan of Care for newly admitted residents. The policy states a 24 Hour Care Plan guides provision of care from the time of the resident transfer/admission until the Interdisciplinary Care Plan is completed and to provide a [NAME] with the Electronic Medical Record (EMR) for resident care direction. R266's undated Face Sheet documents R266 admitted to facility on 3/1/24. R266's undated medical diagnosis list documents R266's medical diagnoses of Local Infection of the Skin and Subcutaneous Tissue, Cellulitis Unspecified, Diabetes Mellitus Type II, Chronic Venous Hypertension with Ulcer and Inflammation of Bilateral Lower Extremities,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent cross contamination of pressure ulcers during pressure ulcer wound care and failed to complete wound treatments for two (R45, R266) residents out of four residents reviewed for Pressure Ulcers in a sample list of 33 residents. Findings include: 1.) R45's undated Face Sheet documents R45 admitted to the facility on [DATE]. This same Face Sheet documents R45's medical diagnoses of Right Hip Pressure Ulcer Stage IV, Morbid Obesity, Acute Respiratory Failure with Hypoxia, Sepsis, Diabetes Mellitus Type II, Cognitive Communication Deficit, and Embolism and Thrombosis of Deep Veins of Right Lower Extremity. R45's Physician Order Sheet (POS) dated March 2024 documents a physician order to cleanse Right Lateral Hip wound with gauze and 1/4 strength bleach solution, apply Gentamicin Sulfate 0.1% topical ointment to periwound and in wound tunnel. Soak roll gauze in 1/4 strength bleach solution and pack into wound after Gentamicin placed into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a safe environment for use of oxygen in the presence of electrical heating devices and flammable materials in the facility beauty shop. This failure affects two residents (R11 and R48) out of nine reviewed for accidents and safety on a sample list of 33. Findings include: On 3/5/24 at 10:40 AM, R11 was in the beauty shop wearing oxygen tubing on her face and nose and actively receiving oxygen therapy from a portable liquid oxygen tank flowing at 2 liters per minute through a nasal cannula (tube connecting the oxygen tank to the resident's nose). V7, Beauty Shop Operator, was in the process of drying R11's hair with a hand-held electric blow dryer (glowing orange electrical coils and an electric fan motor which produces sparks, ignition source) approximately one foot from R11's head. R48 was seated in a wheelchair inside the beauty shop approximately 6 feet away from R11 and the hair dryer being used by V7. R48 was also wearing oxygen tubing on her face and nose and actively receiving oxygen therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide complete perineal care for one resident (R8) of one resident reviewed for perineal care in the sample list of 33. Findings include: R8's undated Face Sheet documents R8's diagnosis as: Chronic Kidney Disease, Stage 2. R8's Care Plan dated 2/15/24, documents R8 is incontinent of bowel and bladder, clean perineal area with each incontinent episode. On 3/7/24 at 11:00 AM, V18 Certified Nursing Assistant (CNA) provided perineal care to R8. During this care, V18 wiped R8's outer labia and failed to spread the labia to wipe the inner labia. At this same time, V18 cleansed R8 buttocks but failed to clean R8's anal area. On 3/7/24 at 11:20 AM, V2 Director of Nursing (DON) stated V18 should be following the perineal care policy. The facility's Perineal Care policy dated Revised 12/22, documents cleanse the outer skin folds, open all skin folds, cleanse from front to back, cleanse the anal area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain and implement physician orders for Continuous Positive Airway Pressure (CPAP) machine settings and cleaning schedules and failed to properly store Nebulizer tubing. These failures have the potential to affect three residents (R12, R17, R21) out of three reviewed for respiratory care on a sample list of 33. Findings include: 1. On 3/5/24 at 10:06 AM, there was a CPAP machine in R12's room next to R12's bed. On 3/5/24 at 10:20 AM, R12's Care plan focus area initiated 7/15/22 documents (R12) has OSA (Obstructive Sleep Apnea) and utilizes a CPAP machine. This Care Plan focus area documents nursing interventions for the CPAP machine include, Clean CPAP per orders. R12's medical record including R12's Physician Order Sheet, Treatment Administration Record, and Care Plan, did not contain any specific orders for pressure settings to be utilized for the CPAP machine during use, nor a cleaning schedule for R12's CPAP. On 3/5/24 at 12:54 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely assess a resident for injury following a coffee spill, document an initial wound assessment, and ensure a wound was covered with a protective dressing for one resident (R1) of three residents reviewed for accidents in the sample list of three. Findings include: R1's Minimum Data Set, dated [DATE] documents R1 has Dementia with moderate cognitive impairment. R1's Care Plan dated with an initiated date of 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. V18 (Certified Nursing Assistant/CNA) written Statement dated 8/14/23 documents at 4:30 PM (on 8/13/23) a dietary staff member reported that R1 had spilled coffee and R1's pants may be wet. V18's statement documents V18 went to the dining room and did not notice R1's pants to be soiled. There is no documentation that R1's pants were changed or that R1's skin was immediately assessed for injury or that V18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.