Health inspection·August 27, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bilateral heels. Areas assessed. R2 denied pain. Wound nurse, (physician) and Power of Attorney notified. Foam dressings applied and heels floated. R2's Physician's orders document a treatment to cleanse wound, apply skin prep and a bordered foam dressing was initiated at that time.R2's Multi Wound Chart Details by V9, Wound Care Physician's Assistant dated 8/19/25 documents Initial Exam Stage 2 Pressure Ulcer Right, Distal, Plantar, Posterior, Inferior, heel measuring 1.0CM in length 0.5 CM in width 0.1 CM in depth and Left Distal, Plantar, Posterior, Inferior, heel measuring 3.0CM in length 1.5 CM in width 0.1 CM in depth. R2's Wound assessment dated [DATE] by V7 wound nurse documents the wounds are Deep Tissue Injuries as opposed to Stage 2 Pressure Ulcers. V9's documentation states the wounds were acquired 8/10/25 as opposed to 8/13/25. V9's wound care orders included in the 8/19/25 document state Cleanse wound with 0.125% Dakin's solution while the actual order being administered states to cleanse with wound cleanser. On 8/26/25 at 10:00AM, V7 stated (R2's) heel wounds are closed unstageable pressure ulcers. You would not want to clean intact skin with Dakin's solution. The order in place is to clean with wound cleanser apply skin prep and cover with foam border dressing. V7 removed in place foam border dressings from R2's heel wounds. R2's left heel observed to have a half dollar sized purple intact Deep Tissue Injury. R2's right heel observed to have a dime sized purple Deep Tissue Injury.On 8/26/25 at 1:35PM V9 stated (R2's) heel wounds are Deep Tissue Injuries. V9 verified Dakin's Solution would not be used for intact skin. When asked why his wound assessment indicated both wounds are Stage 2 Pressure injuries V9 stated I believe I documented that by mistake. When asked what type of experience or certification V9 maintains in Wound Care V9 stated I've been a Physician's Assistant for a long time. V9 did not indicate any specialized wound care experience or certification. Event ID: Facility ID: 145603 If continuation sheet Page 2 of 4 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 08/27/2025 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)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Actual harm Based on interview and record review the facility failed to identify potential triggers for Post Traumatic Stress Disorder (PTSD) and failed to initiate resident centered interventions to address PTSD for one resident (R1) admitted to the facility with a diagnosis of PTSD of three residents reviewed for admission transfer discharge rights in a sample list of nine residents. Consequently, R1 experienced an exacerbation of behavioral symptoms leading to emergent hospitalization.Findings include:R1's progress note documents R1 was admitted to the facility from home on 7/17/25 at 3:09PM. R1's physician's note dated 7/1/25 documents R1 is a candidate for assisted living. R1's most recent diagnoses list includes the following diagnoses: Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Lupus Erythematosus, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Major Depression, Osteoarthritis, and Sedative/Hypnotic/Anxiolytic Dependence.R1's Brief Trauma Questionnaire dated 7/28/25 fails to address R1's Diagnosis of PTSD and fails to identify possible triggers for behavior. R1's Care Plan updated 8/19/25 does not include interventions or possible triggers in relation to R1's PTSD.Surveyor attempted to reach R1 by phone on 8/25/25 at 8:13AM, 8/26/25 at 1:52PM and 8/27/25 at 10:00AM. The message mailbox was full. Unable to leave message.On 8/25/25 at 12:00PM V5, Social Service Director stated R1 was high functioning. V5 stated he had spoken with R1 in regard to whether or not R1 might be interested in assistance to find a less restrictive placement option. V1, Administrator and V5 both stated R1 was never going to be involuntarily discharged it was just an offer of assistance should that be R1's wishes. V5 stated after that conversation R1 became very suspicious of staff and seemed to believe she was being discharged which was not the case.On 8/11/25 at 11:49AM, V16 Licensed Clinical Social Worker (LCSW) contracted by the facility documented in R1's progress notes Client presents in severe emotional distress on this date. Client appears to be in a manic episode and experiencing symptoms of posttraumatic stress disorder. Client is verbally stating she is getting kicked out of the nursing home and put on the streets to be homeless, which is not true confirmed by multiple administrators and staff at this facility. Client is seen packing her bags and using her roommate's phone to make phone calls to leave. Client does not have anywhere to go. Client is making multiple accusations towards staff that they are kicking her out based on her age, race, and disabilities although staff is not making client leave. Through assessment, clinician identifies client is experiencing a manic, post-traumatic stress disorder trigger due to her challenges in interpersonal relationships and childhood/family trauma. Client does not feel welcome here and due to this personal belief, she is unable to be redirected or regulated emotionally at this time. Clinician utilized multiple interventions, including mindfulness of deep breathing, sorting through thoughts, and emotions, identifying emotions, encouragement of active listening, and removing client from the stressful environment without any success. Social services director and administration are involved in client's care. Client will be sent out for a psychiatric evaluation if she is agreeable or leaving AMA (Against Medical Advice).V1 Administrator's Social Service Note dated 8/11/25 at 5:21PM stated At approximately 5:00pm, (R1) was at front door demanding to be let out as she wanted to leave the facility. She had her belongings packed. When asked to sign AMA paperwork, (R1) stated she would not sign the papers as she did not see a doctor. (R1) was informed that if she left the facility the police would be called as the facility was looking out for her safety. (R1) stated to call the police as she was leaving. (R1) exited front door. The police were notified. V17, LPN, (Licensed Practical Nurse) stayed with (R1), until police arrived. (V19 local police officer) was informed of the incidents that occurred throughout the day, that lead resident to this point. (V19) stated that the conversation that was had with the resident in the parking lot, and writer was recorded on camera. (V19) stated even Residents Affected - Few Note: The nursing home is disputing this citation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145603 If continuation sheet Page 3 of 4 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 08/27/2025 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)

F 0699 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete though she did not sign AMA paperwork, (R1) was alert and oriented and willing to make the decision to leave AMA without signing papers. (V19) stated (R1) would become the concern of the Police Department at this time. Staff continued to monitor (R1) and (V19). At 5:42pm, (V19) continued to remain with (R1) in the parking lot and an ambulance arrived on scene. EMT entered facility and received paperwork for transport to (hospital). (family member) was updated on the situation and was appreciative of the update. On 8/27/25 at 10:45AM V17, verified that V17 was observing R1 at all times from the time R1 went into the parking lot until R1 consensually left in the ambulance to be transferred to the hospital for evaluation and treatment. V5 stated R1 then opted to be discharged from the hospital in the care of a family member. Event ID: Facility ID: 145603 If continuation sheet Page 4 of 4