Inspection·July 1, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review the facility failed to prevent a fall by failing to explain cares and ensure safety while elevating a bed for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 falling from the bed to the floor and sustaining a skull fracture with a brain bleed. Finding include: R1's hospital records dated 6/15/24 document R1 was sent to the emergency room due to a fall. This record documents, (R1) was being repositioned and rolled out of bed at nursing home. (R1) has obvious signs of head trauma. R1's CT (computerized tomography) scan showed intracranial hemorrhage (brain bleed), acute C1 and C2 fractures (spinal fractures), and left frontal calvarium fracture (skull fracture). R1's Incident Note dated 6/15/2024 at 12:45 AM documents, (R1) was being bed checked by CNAs (V3 and V4 Certified Nurse's Assistants). While rolling (R1) to change (R1) rolled out of bed and fell to floor. CNA attempted to catch (R1) but was unable to. (R1) has laceration on (left) upper forehead. Also noted raised area on (left) top of head. This note also documents that R1 was sent to the emergency room. R1's undated Fall with Injury report documents an interview with V4 that states, We (V3, V4) were about to pass (R1's) room when we noticed she was laying fairly close to the edge of her bed. As we approached the room, (V3) was entering the room and I was still in the doorway. (R1) pulled the blanket off and immediately tumbled to the floor. It happened so fast; we were unable to catch her. This report also documents an interview with V3 that states, I asked (V4) to help me with my residents and we went in to reposition (R1). When I first saw her, she was laying in the edge of the bed, wrapped up in her cover, with it over her face. I think that's the only thing that kept her from falling from the bed before we got to her. As I was walking around the bed and raising it, (R1) started to move and pulled her blanket back, at that point she tumbled from the bed. It happened so quick that I couldn't get to her to catch her. On 7/1/24 at 9:51 AM, V3 stated in regard to R1's fall on 6/15/24 when V3 and V4 walked past R1's room she was lying to close to the side of the bed. V3 stated they entered the room and V3 was starting to raise the bed up when R1 pulled the cover back. V3 stated she attempted to run around to catch her, but she fell to the floor. On 7/1/24 at 12:42 PM, V4 stated in regard to R1's fall on 6/15/24 that V3 asked her to help her pull up her residents. V4 stated R1's bed was in a lower position, and she was at the edge of the bed. (continued on next page) 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 2 Event ID: 145603 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 145603 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Hc of Paxton on Pells 1001 East Pells 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)