Inspection·June 8, 2023

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit a comprehensive Minimum Data Set within the 14-day requirement after determining a significant change in a resident's health status. This failure affects one resident (R28) out of three reviewed for pressure ulcers on the sample list of 28. Residents Affected - Few Findings include: R28's Minimum Data Set (MDS, resident assessment instrument) dated 1/31/23 documents R28 required supervision and set up assistance to accomplish bed mobility, surface to surface transfers, ambulation in the room and corridor, eating, and toileting. This same MDS documents R28 required supervision and physical assistance from one staff member to accomplish locomotion on and off the nursing unit with a walker, and dressing. This MDS documents R28 required extensive assistance of one staff member to accomplish bathing. This MDS documents R28 is not steady in transitions such as rising from sitting to standing, walking, turning around, and during surface-to-surface transfers but is able to stabilize self without staff assistance. This MDS documents R28 is occasionally incontinent of bladder, and always continent of bowel. This MDS documents R28 experienced no skin conditions such as unhealed pressure ulcers, infections, nor other lesions of the feet. This MDS documents R28 utilized pressure relieving devices on the chair and bed. This MDS documents R28 had not received any special treatments, programs, or procedures, such as intravenous therapy or quarantine. This MDS documents R28 received no skilled therapy services such as Speech Therapy, Physical Therapy, nor Occupational Therapy. This MDS documents R28's physician had not visited nor changed R28's orders. R28's MDS dated [DATE] (modified) documents R28 required extensive assistance of one staff member to accomplish bed mobility, dressing, toileting, and personal hygiene (all significant declines requiring revision to the plan of care). This same MDS documents R28 required extensive assistance of two staff members to accomplish surface to surface transfers, locomotion on and off the nursing unit, and accomplished no ambulation (all significant declines requiring revision to the plan of care). This MDS documents R28 was dependent on one staff member for bathing (decline). This MDS documents R28 is unsteady rising from sitting to standing, during surface-to-surface transfers, is unable to stabilize without staff assistance, and now accomplishes locomotion with a walker or wheelchair (decline). This MDS documents R28 is frequently incontinent of bladder and always incontinent of bowel (significant decline). This MDS documents R28 experienced an unstageable pressure ulcer, infections, and other open lesions of the feet (significant decline requiring revision to the plan of care). This MDS documents R28 utilizes pressure relieving devices on the chair and bed, nutrition, and hydration interventions to manage skin problems, pressure ulcer care, applications of ointments or medications other than to the feet, and application of dressings to the feet (significant decline requiring revision to the plan of care). This MDS documents R28 received intravenous medications, and isolation or quarantine for active infectious disease (significant decline requiring revision to the plan of (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 7 Event ID: 146010 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 146010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Pontiac 300 West Lowell Pontiac, IL 61764 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)