Inspection visit

InspectionApril 14, 2023

ACCOLADE PAXTON SENIOR LIVINGCMS #1454495 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on interview and record review, the facility failed to provide a notice of bed-hold to a resident nor the resident's representative upon transfer of the resident to the hospital. This failure affects one(R16) of three residents reviewed for hospitalization/discharge on the sample list of 33. Findings include: R16's Census List printed 4/13/23 documents R16 was hospitalized [DATE], and 11/10/22. R16's Electronic Medical Record does not have documentation that bed hold notification was provided to R16 nor V17 (R16, Family Representative) on 2/2/23 or 11/10/22. On 4/13/23 at 1:20 pm, V1 (Administrator) acknowledged that there is no documentation found in R16's electronic medical records to indicate that a bed hold notice was sent with R16 to the hospital or that V17 was provided written bed hold notices. V1 stated V1 had the medical records department check through documents that had not been scanned to R16's chart. V1 also stated the medical records department was not able to find any documentation to support that the facility provided bed hold/written notices. The facility undated, blank policy form Statement of Resident Rights Regarding Bed Hold documents the following: 1. When a resident of the nursing home is transferred to a hospital (,) when the resident leaves on therapeutic leave, the resident has the right to request that his or her bed be held (,) continuously available for the residents return to the nursing home. Such request is called bed hold. The same Statement of Resident Rights Regarding Bed Hold from documents 10. The undersigned (no evidence of this documentation for R16) state that this notice was provided to the resident or handed to or mailed to a member of the resident's family or legal representative on the dates (form is a blank copy) indicated below. On 4/14/23 at 8:05 am, V6 (Social Service Director/SSD) confirmed V6 is responsible for sending the resident family representatives a copy of the bed hold. V6 also stated the family are notified by the nurses by phone, and a hard copy of the form is supposed to be sent with the resident. V6 also stated V6 has been busy and cannot remember if the bed hold forms were mailed 2/2/23 or 11/10/22 to R16's family. V6 also stated V6 recognizes that if V6 does not document, there is no way to confirm if the bed hold forms were sent to a residents' family representative. I know I am supposed to chart that I sent the resident families (representative) a copy of the bed hold. I just don't always have time to. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 145449 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to transcribe and implement R32's physician ordered pressure ulcer treatment. R32 is one of five residents reviewed for pressure ulcers on the sample list of 33. Residents Affected - Few Findings include: On 4/12/23 3:00 pm - 4:30 pm, V12 (Wound Physician) was in the facility completing wound assessments on numerous residents. V12 updated R32's physician's order for pressure ulcer treatment while in the facility. V12 (Wound Physician) completed R32's Specialty Physician Wound Evaluation and Management Summary dated 4/12/23, which documents the following assessment and order: Left lateral calf, full thickness, Stage IV pressure ulcer measurements: Wound Size (L x W x D) (Length by width by depth): 0.6 x 0.3 x 0.3 cm (centimeters) Surface Area: 0.18 cm Undermining (depth under the wound surface): 0.5 cm. at 12 o'clock Exudate: Moderate Serous Slough: 30. R32's same Specialty Physician Wound Evaluation and Management Summary note documents R32's Stage IV, pressure ulcer wound treatment plan order as follows: DRESSING TREATMENT PLAN, PRIMARY DRESSING FREQUENCY LENGTH OF TX (treatment) (DAYS) NOTE, Add (wound treatment order) Pack wound cavity with collagen powder (enzymatic debridement agent used inside wound), once daily 30 (days). Discontinue (wound treatment order) Pack wound cavity and tunnel with collagen powder mixed with TAO (triple antibiotic ointment). SECONDARY DRESSING FREQUENCY LENGTH OF TX (DAYS), NOTE, Continue Tape (Retention) once daily 30 (days), ABD (large absorbent cotton pad), once daily 30 (days) PERIWOUND DRESSING FREQUENCY LENGTH OF TX (DAYS) NOTE, Continue Skin Prep (protective liquid film dressing to protect the healthy surrounding tissue), Once Daily 16 (days). R32's Physician Order dated 4/13/23, new treatment order was transcribed incorrectly as follows: Left lateral calf-remove old dressing, remove old collagen (powder), clean with wound cleaner, pack (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound cavity and tunnel with collagen powder, cover with abd, secure with tape daily. (R32's transcribed treatment order did not include the peri wound for skin prep ordered by V12 as noted above). On 4/13/23 at 2:00 pm, R32 was lying in bed on an air mattress with feet elevated to float heels. V8 (Registered Nurse/ Wound Nurse) and V14 (Certified Nursing Assistant/CNA) entered R32's room, provided privacy, completed hand hygiene, and donned a protective gown and clean gloves, for enhanced precaution during wound treatment. V8 set-up a clean field and opened treatment dressing packages. There was not a skin prep package present with the treatment supplies. V8 and V14 repositioned R32 on R32's back, with R32's left leg positioned slightly inward. V8, washed hands and donned new gloves to remove a soiled. There was a moderate amount of serous drainage noted. R32's Stage IV pressure ulcer wound bed was moist and red. V8 disposed of the soiled wound dressing and again completed hand hygiene and donned new gloves. V8 cleansed the Stage IV pressure ulcer with wound cleaner and a four-by-four-inch gauze pad. V8 applied collagen powder by rolling a cotton tip applicator one time, across the surface of R32's wound and surrounding healthy skin. A scant amount of collagen powder adhered to the surface. V8 did not pack R32's wound cavity with collagen powder. V8 did not apply skin prep to the surrounding healthy peri wound area, as V12 (Wound Physician) ordered. V8 (RN/ Wound Nurse) stated, I didn't do (apply collagen powder) the undermining (tissue) that V12 said R32 had. (V12, documented in the above evaluation note. 'Undermining (depth under the wound surface: 0.5 cm. at 12 o'clock'). I did not probe (check with a cotton tip swab) to find it though. I thought rolling the collagen powder over the top was enough. I did forget the skin prep. I guess I didn't follow V12's order exactly, as I should have. The facility policy Treatment Administration dated 4/2023 documents the following: Procedure: 1. Administration of Treatment: a. Review the physician orders in the EHR (electronic health record) and place all necessary supplies in treatment cart. Treatments may require supplies such as, dressing, solutions, ointment, eye drops, enemas, suppositories, catheters, oxygen, IV (intravenous, sterile, occlusive dressing) tube feeding equipment, etc. c. Complete treatment as ordered (physician order) utilizing stringent infection prevention and control measures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility care plan dated [DATE] for R68 documents R68 was admitted to the facility on [DATE]. The care plan documents the following diagnoses for R68: History of Falling, Difficulty in walking and Repeated falls. The Minimum Data Set (MDS) dated [DATE] documents R68 requires two plus persons assist for all activities of daily living to include toileting, transfers, and personal hygiene. The MDS documents R68 functional abilities for mobility requires two plus person physical assist. for bed mobility, transfers and for locomotion. R68 uses a wheelchair to help her move within the facility. The facility fall report dated [DATE], document R68 had a fall at 8:20 PM. The fall report documents R68 was observed lying face down. Right leg bent at the knee drawn up towards abdomen. Left leg was straight. Wearing no socks. No call light on at this time. Only light on was above the sink. R68 states, I was trying to walk home. I fell and hit my head and need to go to the hospital R68 had a Hematoma on the top of her scalp. The fall report lists the predisposing environmental factors as: Poor lighting, Confused, Incontinent, Weakness, Gait imbalance and impaired memory. R68 was also wearing improper footwear and was ambulating without assistance. Progress note dated [DATE] at 2:29 AM for R68 documents R68 being admitted to the hospital for acute encephalopathy and a closed head injury. Nurse from hospital reported R68 continues to be hypertensive and due to her being on blood thinners, MD wants to monitor closely for intracranial bleeding. R68's undated baseline care plan does not document where the facility develops and implement fall interventions for R68 to help prevent falls. V2 (DON) stated on [DATE] at 1:11 PM, The baseline care plan did not have any interventions for falls. R68 was transferred to another facility when R68 was discharged from the hospital. Based on interview and record review, the facility failed to maintain equipment in safe working order and failed to develop and implement fall interventions for two of four residents (R34, R68) reviewed for falls on the sample list of 33. Findings include: The facility's Fall Prevention Program dated [DATE] documents staff are to initiate and provide ongoing risk reducing interventions. 1. R34's Medical Diagnoses list dated [DATE], documents R34 is diagnosed with Dementia, Muscle Wasting and Atrophy, Muscle Weakness, Unsteadiness on Feet, and Abnormal Posture. R34's Minimum Data Set, dated [DATE], documents R34 is totally dependent on at least two staff members for transfers. R34's Fall Risk Assessment, dated [DATE], documents R34 is at High Risk for falls related to Intermittent Confusion, Three or More Falls in the Past Three Months, Chair Bound, Decreased Muscular Coordination, and Requires Assistive Devices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R34's Care Plan, dated [DATE], documents R34 has a Self-care Performance Deficit due to Activity Intolerance, Fatigue, Impaired Balance, and Stroke. R34 has a Limited Physical Mobility related to Trans-Metatarsal Amputation of Right Foot. R34 is at High Risk for Falls related to Actual Falls, Weakness, Drowsiness, Decreased Safety Awareness, and Impaired Balance. R34's Post Fall Evaluation dated [DATE] documents R34 had an unwitnessed fall out of bed at approximately 3:00 AM. The same Evaluation documents the reason for the fall was that R34's air mattress was only partially inflated. R34 sustained a bloody nose and complained of pain to her right arm. The same evaluation documents a contributing factor to the fall was a Bed Malfunction. R34's Fall Incident Investigation dated [DATE] documents the Root Cause of R34's [DATE] fall was that R34's Air Mattress malfunctioned. On [DATE] at 9:42 AM, V2 (Director of Nursing/DON) confirmed the root cause for R34's fall out of bed on [DATE] was determined to be because R34's air mattress's Cardio-Pulmonary Resuscitation (CPR) cord was pulled and the mattress was only partially inflated, leaving it unstable. V2 confirmed staff should be familiar with the air mattress' functions and recognize when a CPR cord is pulled unnecessarily. Staff should have made sure R34's air mattress was properly inflated in order to ensure R34's safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some Based on observation, interview and record review, the facility failed to: maintain residents respiratory equipment in clean and sanitary condition, follow the facility oxygen policy to obtain physician orders for oxygen administration, monitor blood oxygen saturation (SATS) level as ordered by the physician, provide physician ordered oxygen tubing bags to keep excess tubing off the floor, fill and/or replace oxygen humidifiers and nasal cannula, record the date and initial the oxygen tubing and humidifier bottles, and failed to obtain a physician order for care of a resident's positive airway pressure device (CPAP). These failures affected seven of seven residents (R3, R4, R12, R21, R39, R60, R67) reviewed for respiratory treatment on the sample list of 33. Findings include: 1. R3's Medical Diagnosis sheet updated 3/29/23 documents the following diagnoses: CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, SHORTNESS OF BREATH, History ATELECTASIS (collapsed lung). R3's Minimum Data Set (MDS) documents dated 4/03/23 documents R3's Brief Interview of Mental Status (BIMS) score of nine out of a possible 15, indicating moderate cognitive impairment at the time of the assessment. R3's Physician Order Sheet (POS) 4/12/23 documents: O2 (oxygen) AT 2-5L/MIN (liters per minute) PER N/C (nasal cannula), TO KEEP SATS (>) greater 90% (percent), as needed for Shortness of Breath. Oxygen per NC 2-5L as needed to keep o2 Sat>90%. AND every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED Active 4/4/2023. R3's same POS documents the following: Change 02 humidifier 500cc and 02 tubing every Sunday, no directions specified for order. and O2 TUBING/NEB EQUIPMENT CHANGE, no directions specified for order. On 4/12/23 at 10:24 am, R3 was seated in R3's wheelchair bedside. On the opposite side of the bed, R3's oxygen tubing was coiled under R3's oxygen concentrator. The refillable oxygen humidifier bottle and tubing were undated. R3 stated, It is always on the floor like that, and I do not know if anybody ever changes it. On 4/12/23 at 10:28 am, V10 (Registered Nurse/RN) observed R3's oxygen equipment and stated There is no date on anything, and the tubing (oxygen) should not be on the floor. I will be getting plastic bags for storing them, like they are supposed to be. R3's 4/1/23- 4/30/23 Medication Administration and Treatment Administration record does not document R3's blood oxygen saturation level or oxygen equipment changes. 2. R4's Physician Order Sheet (POS) dated 4/1/23- 4/30/23 documents the following: Contact Isolation form Metapneumovirus (Upper Respiratory infection) through 4/14/23. The same POS does not document an order for oxygen administration. R4's Diagnoses Sheet updated 4/11/23 documents the following: Acute Upper Respiratory Infection, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Unspecified, and Other Alveolar and Parieto-Alveolar Conditions. Level of Harm - Minimal harm or potential for actual harm R4's Medication Administration Record and Treatment Administration Record dated 4/1/23- 4/30/23 does not document O2 administration or equipment change. Residents Affected - Some On 04/12/23 at 10:52 am, R4 was lying in bed. R4 had oxygen administration through a nasal cannula at two liters. R4's oxygen tubing and oxygen pre-filled humidifier bottle were dated of 4/3/23. V10 (RN) confirmed observation and stated R4's oxygen tubing and humidifier bottle were not changed either. I see there is a theme here. I will get these (oxygen issues) taken care of. 3. R12's Medical Diagnoses sheet updated 2/27/23 documents the following diagnoses: Covid-19 Pulmonary 2/27/2023, Shortness of Breath, and Other Alveolar and Parieto-Alveolar Conditions. R12's Physician Order Sheet dated 4/1/23-4/30/23 documents the following: O2 tubing equipment change: Date and initial tubing. Place tubing in plastic bag at bedside when not in use. On 04/12/23 at 10:32 am, R12 was seated in her wheelchair. R12's oxygen/nasal cannula tubing was attached to a portable oxygen tank. R12's oxygen/nasal cannula tubing was dated 4/3/23. V10 (RN) confirmed the observation and stated R12's tubing (oxygen/nasal cannula) should have been changed on 4/10/23. 4. R21's Medical Diagnoses Sheet updated 7/27/22 documents the following diagnoses: Other Alveolar and Parieto-Alveolar Conditions. R21's Physician Order Sheet 4/12/23 does not document an order for oxygen administration until after observation documented below. R21's Minimum Data Set, dated [DATE] document R21's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. On 04/12/23 at 10:50 am, R21 was lying in bed. Oxygen was being administration per nasal cannula at two liters per minute. There were no date or initials on refillable humidifier bottle or oxygen tubing. R21 stated I am not sure of the date the last time it was changed, maybe a week ago. V10 (RN) confirmed the observation that R21's oxygen tubing and humidifier bottle were not dated. V10 stated, R21's oxygen tubing and humidifier bottle should have been changed and dated Sunday. 5. R39's Diagnoses Sheet dated 12/29/22 documents the following diagnoses: Centrilobular Emphysema, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Respiratory Failure with Hypoxia, Personal History of Other Diseases of the Respiratory System, Pleural Effusion, Not Elsewhere Classified, Abnormal Pulmonary Function Studies, Shortness of Breath, Other Nonspecific Abnormal Findings in Lung Field, and Dyspnea. R39's Physician Order Sheet (POS) dated 3/17/23 documents the following: Hospice provider RN (Registered Nurse) or HHA (Home Health Aide) visit per hospice schedule. The same POS documents the following: Oxygen: May use two to four liters (per minute) to maintain blood oxygen saturation above 93 percent. If more than three liters needed, notify physician. Oxygen (administer) at three liters per nasal cannula continuous. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The same POS documents: Change 02 humidifier 500 cc (cubic centimeter capacity) and 02 tubing every Sunday. No directions specified for order. The same POS documents: O2 tubing /neb (nebulizer) equipment change tubing and neb weekly, and prn (as needed). R39's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 4/1/234/12/23 does not document that R39's O2 tubing or refillable humidifier have been changed this month. The same MAR and TAR do not document R39's blood oxygen level was measured in April 2023. On 4/11/23 at 10:30 am, R39 was lying in bed. Oxygen concentrator running at three liters per minute via nasal cannula. Tubing was appropriately labeled as changed 4/10/23 (not documented on MAR or TAR). R39's oxygen concentrator humidifier bottle was completely empty and undated. R39's oxygen tubing was coiled on the floor between R39's bed and oxygen concentrator. R39 stated, I asked them (unidentified) to fill the humidifier bottle this morning. They are aware it is dry. On 04/12/23 10:10 am R39 was lying in bed. R39's oxygen concentrator refillable humidifier bottle remained completely empty and undated. R39's oxygen tubing continued coiled between the bed and the bedside oxygen concentrator. R39 stated, I still haven't gotten the new bottle of water on my oxygen. I asked yesterday, they did nothing. My nose is very dry and irritated. On 04/12/23 at 10:15 am, V10 (RN) stated, R39's humidifier bottle should have been changed and dated. He is on 3-4 litters and requires his humidifier bottle to be filled more frequently than most. The O2 (oxygen) tubing should never be on the floor. 6. R60's Physician Order Sheet dated 4/12/23 does not document an order to administer oxygen. R60's Medical Diagnoses Sheet dated 2/27/23 documents the following diagnoses: Other Alveolar and Parieto-Alveolar Condition and COVID-19 Pulmonary. R60's Minimum Data Set, dated [DATE] documents R60's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. On 4/12/23 at 10:47 am, R60 was lying in bed with oxygen concentrator administering oxygen at two liters per minute via a nasal cannula. R60's oxygen tubing and empty refillable humidifier bottle were both dated 4/3/23. V10 (RN) confirmed R60's oxygen tubing and empty humidifier bottle were both dated 4/3/23. V10 stated, R60's tubing should have been changed 4/10/23. R60's humidifier bottle should be changed at the same time, or more frequently. It should never run completely dry. R60 then pulled her nasal cannula out of her nares and directing the oxygen tubing towards her eyes. R60 stated, My nose tube (nasal cannula) has not been putting out the air like it is supposed to. I can usually test it like this, but the air isn't coming out like it should. That bottle of water has been emptying since yesterday. On 4/12/23 at 1:30 pm, R60 stated, A nurse (unidentified) put oxygen (no physician order) on me (R60) about a month ago, because I had some shortness of breath. I thought it was because of my allergies. I guess I need it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V10 (RN) confirmed R60 does not have an order for oxygen. V10 stated, I will have to call V11 (Nurse Practitioner/NP) and get an order. That could be why the tubing and humidifier bottle had not been changed. It wouldn't be on the MAR without an order. The facility policy Oxygen Administration updated 02/2021 documents the following: PURPOSE: The purpose of this procedure is to provide guidelines for oxygen administration. To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. POLICY: Oxygen therapy will be administered to the resident only upon the written order of a licensed physician. It will be administered by way of an oxygen mask, nasal cannula and/or a nasal catheter. RESPONSIBILITY: It is the responsibility of the Charge Nurse to ensure that residents who have an order for oxygen are receiving the proper amount via the proper way, per physician order. EQUIPMENT: A. Portable oxygen tank/O2 tank. Concentrator B. Nasal cannula, nasal catheter, mask (as ordered) C. Humidifier bottle PROCEDURE: 14. CARE AND USE OF PREFILLED DISPOSABLE HUMIDIFIERS: A. PREFILLED disposable humidifiers will be changed when necessary. G. Set the flow meter to the rate ordered by the physician. I. Label humidifier with date opened. Tubing will be changed as needed. 15. CARE AND USE OF REUSABLE HUMIDIFIERS: A. Remove humidifier from sterile wrapper. B. Fill with sterile distilled or sterile deionized water to fill line. C. Attach humidifiers to flow meter by screwing nut onto the flow meter. This fit must be tight to ensure accurate flow of oxygen to the resident. D. Attach mask or cannula tubing to humidifier. E. Set the flow meter to the rate ordered by the physician. F. Place mask or cannula on resident as indicated above. G. Label humidifier with date opened. Tubing will be changed as needed. 15. CARE AND USE OF REUSABLE HUMIDIFIERS; A. Remove humidifier from sterile wrapper. B. Fill with sterile distilled or sterile deionized water to fill line. C. Attach humidifiers to flow meter by screwing nut onto the flow meter. This fit must be tight to ensure accurate flow of oxygen to the resident. D. Attach mask or cannula tubing to humidifier. E. Set the flow meter to the rate ordered by the physician. F. Place mask or cannula on resident as indicated above. G. Label humidifier with date opened. Tubing will be changed as needed. 18. PRECAUTION: CONSTANT FLOW OF OXYGEN CAN CAUSE DRYING AND THICKENING OF NORMAL SECRETIONS RESULTING IN LARYNGEAL ULCERATION. 7. V67's Facilities Census documents R67 was admitted to the facility on [DATE] with the following medical diagnoses, Obstructive Sleep Apnea, and Insomnia. R67's Physician's Order Sheet (POS) has no order for R67's CPAP mask and tubing to be cleaned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 weekly. Level of Harm - Minimal harm or potential for actual harm R67's Care Plan updated on 3/21/23 does not document R67's CPAP (Continuous Positive Airway Pressure) device to be cleaned weekly. Residents Affected - Some On 4/11/23 at 9:46 am, R67 was lying in bed wearing a positive airway pressure device (CPAP). R67 said, no one cleans the mask or tubing, and it should be cleaned weekly. R67 said R67 is not able to clean the mask or tubing. On 4/14/23 at 9:15am, V2 (Director of Nursing/DON) said the nurses should clean the CPAP masks and tubing weekly. V2 said that R67 uses a CPAP, and there should be orders for the cleaning of the CPAP mask and tubing. V2 said it should be documented in R67's Treatment Administration Record (TAR) that the tubing and mask are cleaned weekly. V2 said, I'm not sure why R67 doesn't have an order for R67's CPAP mask and tubing to be cleaned weekly. The (Positive Airway Pressure Device) manufacturer's instructions for use dated November 2017 documents: Wash the CPAP nasal mask or nasal pillows with a mild detergent soap and warm water in the sink weekly. Wash the CPAP tubing weekly in the same manner. Wash the humidifier chamber in soap and water weekly. Disinfect the humidifier chamber with one part vinegar and up to five-parts water. The humidifier chamber should be disinfected to prevent buildup of bacteria. Replace disposable filters once a month and non-disposable filters once a year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete medical record by failing to document that a resident was transferred to the hospital. The facility also failed repeatedly to document three additional days that the resident remained out of the facility, in the hospital. These failures affected one of three residents (R16) reviewed for hospitalization/discharge on the sample list of 33. Findings include: R16's Census List printed 4/13/23 documents the following: On 2/2/23 at 7:45 am R16's Status: Hospital, unbillable leave transferred to (the) hospital. On 2/6/23 at 8:05 pm R16's Status: Active, return from leave.(R16 was out of the facility four days, twelve hours, and twenty minutes) R16's Progress Alert Note dated 02/2/23 at 3:02 am documents the following: Note Text: Resident NPO (nothing by mouth) for surgical appointment. R16 medical record does not document R16 went to the hospital for a surgical procedure 02/2/23. R16's Progress Notes do not document R16's whereabouts until R16 was re-admitted to the facility four days, twelve hours, and twenty minutes after leaving the facility. R16 Hospital ICU (Intensive Care Unit) Progress Note dated 2/2/23 documents a Brief HPI (History Physical) note as follows: R16 was admitted to ICU for closer observation of hemodynamic stability postelective right ureter stent removal, resulting in hypotension and tachycardia. (There is no documentation in the facility progress notes of R16's condition change from one day surgery to an ICU hospitalization). R16's facility admission Summary note dated 2/6/2023 at 9:05 pm documents the following: Time and Method of Arrival (ambulance service): (hospital) ambulance Was Admit/Readmit Assessment Completed: yes Were All Departments Notified? yes Was Physician Notified and Orders Verified: Yes prior to pt. (patient R16) arrival by 0600-1800 (6:00 am6:00 pm) nurse (unidentified). R16 admission Note dated the same 2/6/2023 at 9:05 pm documents the following: Destination: (Long-term care facility). On: (Date and time): 2/6/23 at 2005 (8:05 pm). Arrived via: (facility van, family transport, ambulance): (Hospital) Ambulance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145449 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Paxton Senior Living 450 Fulton Street Paxton, IL 60957 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Vitals: (Temp, Pulse, Respirations, Blood Pressure): b/p-110/50, pulse- 04, 02 (blood oxygen concentration) - 93% (on) room air, respirations-16, temp (temperature)-97.3 F (Fahrenheit) forehead. Level of Harm - Minimal harm or potential for actual harm Orientation: (oriented to room, roommate, call system, etc.): re-oriented to room and call light. Residents Affected - Few Assessments (further assessments completed?): head to toe assessment completed. On 4/14/23 at 11:00 am V1 (Administrator) and V2 (Director of Nursing/DON) stated R16 was admitted to the hospital on [DATE] for a pre-scheduled surgery. V1 and V2 confirmed R16 return to the facility from the surgical procedure hospitalization on 02/6/23. V1 and V2 acknowledged there is no documentation in R16's medical record of R16 being discharged on 02/2/23 to the hospital and no subsequent nurses notes to indicate R16 remained in the hospital. V2, DON stated Nurse (facility) staff will be re-educated to completely document discharge events. The facility policy Contents of the Medical Record dated August 2017 directs staff to ensure that all medical records are maintained according to regulations and guidelines. The same policy direct staff to describe nurse care provided and ongoing notation describing significant observations and development regarding each resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145449 If continuation sheet Page 12 of 12

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the April 14, 2023 survey of ACCOLADE PAXTON SENIOR LIVING?

This was a inspection survey of ACCOLADE PAXTON SENIOR LIVING on April 14, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ACCOLADE PAXTON SENIOR LIVING on April 14, 2023?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed i..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·April 14, 2023