Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accolade Hc Of Paxton On Pells during CMS and state inspections, most recent first.
A cognitively intact resident reported that another resident with dementia and behavioral health diagnoses twice screamed profanities at her in the hallway and dining area, calling her an “F expletive B expletive” and using other harsh, foul language that left her tearful and upset. Staff became aware of the incident when a CNA and an RN observed the resident’s distress and obtained her account, then separated the residents. The abusive resident had a history of anger, refusal of prescribed psychotropic meds, and a prior episode of suddenly cussing at another resident. The Administrator initially concluded that no abuse occurred due to a misunderstanding of the abuse definition, but later acknowledged that the intentional verbal outburst met the policy definition of abuse.
Failure to protect a resident from sexual abuse by another resident. An LPN observed one resident place his hand under another resident’s shirt and move it around her breast, then separated the residents and reported the incident. The resident involved was cognitively intact, while the other resident was cognitively impaired. Staff also stated there had been a prior similar incident involving the same two residents.
A resident with multiple complex medical conditions expired under hospice care, but due to unclear communication and lack of documentation among LPNs and other staff, the funeral home was not notified in a timely manner to remove the body. The remains were discovered by a housekeeper the following day, highlighting a breakdown in shift-to-shift reporting and responsibility for postmortem procedures.
A resident with dementia and multiple mobility issues eloped after an LPN and CNA exited through an employee service door that was not properly secured. The staff did not confirm the door was locked, and the resident followed them outside, becoming locked out and later found knocking on their room window. The facility's policy requiring staff to monitor resident whereabouts and ensure safety was not followed.
A resident with a diagnosis of PTSD was admitted without proper assessment or identification of trauma triggers, and the care plan did not include interventions for PTSD. After a discussion about possible alternative placements, the resident became distressed, experienced a manic episode with PTSD symptoms, and attempted to leave the facility, leading to police and EMS involvement and transfer to a hospital.
A resident with severe cognitive impairment developed multiple pressure ulcers due to the facility's failure to implement and document appropriate pressure relieving interventions. The resident was left in a wheelchair for extended periods without adequate pressure relief, and staff failed to update the care plan or coordinate pain management effectively. The facility's documentation and communication regarding the resident's wounds were inadequate, leading to a lack of timely treatment and intervention.
The facility failed to track culture results and organisms in infection control logs, and staff did not consistently implement Enhanced Barrier Precautions (EBP) or use personal protective equipment as required. This included not wearing gowns during high-contact care and failing to report changes in residents' conditions, such as cloudy urine in a resident with a history of UTIs, leading to hospitalization.
The facility failed to employ sufficient staff with the necessary competencies in food and nutrition services, affecting all 92 residents. The dietary manager lacks certification, and the RD only visits weekly. Concerns about menu nutritional values were raised, and a formal complaint was filed without response. The consulting company has not been onsite, leaving the facility responsible for compliance.
The facility failed to ensure menus and substitutions met residents' therapeutic diets and nutritional needs. During a lunch service, residents on specific diets received inappropriate items, and no fruit was served. The RD raised concerns about the menu not meeting state requirements and filed a complaint. Additionally, a resident with cognitive impairment was given ice cream instead of the prescribed pureed pears, contrary to facility policy.
The facility failed to maintain food safety and storage standards, affecting all 92 residents. Observations revealed food debris, improper storage, and unlabeled items in the kitchen. During meal service, food temperatures were not checked, and cold coleslaw was served above safe temperatures. The in-house dietician expressed concerns about the dietary services, noting the absence of the consulting company managing food services. Facility policies on food storage and safety were not followed, leading to potential health risks.
The facility failed to appoint a qualified Infection Preventionist with the necessary training, affecting 92 residents. The Administrator and nurse managers, who lacked the required training, collectively managed the role before hiring a new Wound Nurse/Infection Preventionist, who also had not completed the necessary training.
The facility failed to notify residents and their representatives in writing about hospital transfers and did not provide bed hold notices for four residents reviewed for hospitalizations. The Director of Nursing and other staff confirmed that bed hold forms were not being completed or sent to families, despite the facility's policy requiring such communication. This issue was consistent across multiple hospitalizations, indicating a systemic problem in the facility's process.
A facility failed to perform proper hand hygiene during catheter care for a resident, as CNAs did not wash hands before donning gloves or after completing care. Additionally, the resident's urinary catheter drainage bag was not consistently covered with a dignity bag, violating the facility's policy.
A resident with severe malnutrition and other health issues experienced a significant weight loss after being readmitted to the facility. The facility failed to obtain a re-admission weight, notify the physician and family, and develop a care plan to address the weight loss, contrary to their Weight Management policy.
A resident with severe cognitive impairment did not have their privacy maintained during wound care. On two occasions, staff, including a wound nurse, a wound nurse practitioner, a CNA, and the DON, failed to pull the privacy curtain, exposing the resident's buttocks and perineal area to the hallway and doorway. This was against the facility's policy requiring privacy during ADLs.
A resident with moderate cognitive impairment and impaired range of motion did not receive necessary therapy or restorative nursing services after transferring to the facility. The resident's care plan lacked documentation for addressing these needs, and the facility's Functional Maintenance Program was not applied. The resident was on antibiotics for pneumonia, delaying therapy screening, but the lack of restorative services was a significant oversight.
A resident slipped from a wheelchair during transport due to improper positioning of a mechanical lift sling, requiring emergency assistance. The facility failed to investigate the incident, document it as a fall, or update the resident's care plan. Additionally, no fall risk assessments were completed in 2024, contrary to facility policy.
The facility failed to maintain proper hygiene and storage for respiratory equipment for two residents. One resident's CPAP mask was left uncovered on the nightstand, and another resident's oxygen tubing was found on the floor without a storage bag. The care plan for the second resident did not address their COPD or oxygen use, despite having a physician's order. Staff confirmed the improper storage and care of the equipment.
A facility failed to limit a PRN order for Lorazepam, an antianxiety medication, to 14 days as per its protocol. A resident was prescribed the medication on a PRN basis for agitation/restlessness, but the order remained active beyond the 14-day limit without reassessment, despite the resident not using the medication since shortly after it was prescribed. This was confirmed by the DON during an interview.
The facility failed to implement effective fall interventions for two residents, resulting in multiple falls and injuries. One resident, with moderate cognitive impairment, experienced several falls, including two with head lacerations. Despite being identified as restless, the facility did not promptly implement new safety measures. Investigations into the falls were inadequate, lacking thorough assessment of contributing factors. Another resident with severe cognitive impairment also fell while attempting to self-transfer, with care plan interventions not consistently followed.
A facility failed to report a potential abuse incident involving two residents. A CNA observed a resident with schizophrenia in the bed of another resident with severe cognitive impairment, kissing them on the cheek. The CNA and an LPN removed the resident but did not report the incident to the Administrator. The Administrator learned of the incident the next day, confirming the failure to report it immediately.
A resident with dementia fell from bed and sustained severe injuries after CNAs failed to explain care procedures and ensure safety during bed repositioning. The resident was startled by the bed's noise and fell before staff could intervene. The care plan required clear communication, which was not followed.
A facility failed to re-evaluate and coordinate discharge plans for a resident with stage three pressure ulcers, resulting in the resident being discharged home without necessary home health services or a wound clinic appointment. The post-acute care coordinator did not document the denial of home health services or notify the nurse practitioner, leading to the resident's subsequent hospitalization.
The facility failed to conduct and document weekly skin assessments, identify a reopened pressure ulcer, notify the physician, and obtain treatment orders for a resident. Significant gaps in documentation and miscommunication among staff led to inadequate pressure ulcer management.
Failure to Protect Resident From Verbal Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal abuse by another resident. One cognitively intact resident (R75), with a BIMS score of 14/15 and no documented delusions, hallucinations, or behaviors toward self or others, reported that another resident (R84) twice screamed profanities at her from the hallway and in the dining area. During these incidents, R84 called her an “F expletive B expletive” and used additional harsh, foul language in an angry tone, causing R75 to cry and feel very upset. R75 did not initially report the first incident to staff and remained worried about her roommate, who stayed in bed much of the time, and about the possibility that R84 could enter their room. On a subsequent occasion, staff became aware of the incident when a CNA pushing R75’s wheelchair asked an RN if she had heard what R75 said, and the RN then learned from a tearful R75 that R84 had just screamed profanities at her in the dining room. The RN observed that R75 became more upset as she recounted the language used, including being called an “F expletive B expletive” and other foul words. The RN reported that her “heart broke” for R75 and confirmed that staff separated the residents and ensured R75 remained with staff while R84 was kept away from other residents. A prior behavior note from the day before documented that R84 had been having a pleasant conversation with another resident when he suddenly became angry and started cussing at her, after which staff separated the residents and sent R84 to the ER due to his medication refusals. R84 had diagnoses including unspecified dementia with moderate cognitive impairment (BIMS 10/15), psychotic disturbance, mood disturbance, anxiety, and depression, and was prescribed multiple psychotropic medications (sertraline, divalproex, trazodone) that he had refused for 16 of 24 days prior to the verbal abuse incident. His care plan noted depression, anger, and refusal of medications. Despite these documented behaviors and refusals, the facility’s abuse investigation initially concluded that abuse had not occurred, based on the Administrator/Abuse Prevention Coordinator’s misunderstanding that abuse required a willful intent to harm rather than a deliberate act. Upon reviewing the facility’s abuse policy, which defines abuse as the willful infliction of injury, intimidation, or punishment and clarifies that “willful” means acting deliberately and not necessarily intending harm, the Administrator acknowledged that R84 had intentionally cursed at R75, confirming that the resident-to-resident verbal abuse met the facility’s definition of abuse.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from sexual abuse by another resident. R4 was documented as cognitively intact on the MDS, while R5 was documented as cognitively impaired. Nursing progress notes state that on 10/17/2025, R4 was seen with his hand underneath R5’s shirt, and the notes also document that the Abuse Coordinator, POA, and Medical Director were notified. An LPN stated he observed R4’s hand underneath R5’s shirt and saw R4 moving his right hand up and around R5’s breast, then immediately separated the residents and reported the incident to the Administrator. The same LPN stated R4 had done this to R5 in December 2024 and that he had reported that prior incident to the Administrator. An LPN stated R4 had recently touched R5 and that the residents were immediately separated, with R4 to be watched at all times while out of his room and assisted to and from the dining room. During observation, R4 was seen supervised by certified nursing staff at lunch with another male resident. R4 stated he put his hand up R5’s shirt because he missed his wife, who only visits occasionally. The Administrator stated she began working at the facility on 10/17/25, immediately started an investigation, and sent initial and final reports to the Illinois Department of Public Health. She also stated that a chart sweep found a prior incident on 12/15/24 in which R4 put his hands up R5’s blouse.
Failure to Communicate and Document Funeral Home Notification After Resident Death
Penalty
Summary
The facility failed to establish clear communication and documentation regarding the notification to a funeral home for the removal of a deceased resident's remains. The resident, who had multiple medical diagnoses including traumatic subdural hemorrhage, dementia, COPD, heart disease, chronic kidney disease stage 4, anxiety disorder, scoliosis, GERD, and a history of repeated falls, expired at 11:52 AM under hospice care. Although the hospice nurse and family were present at the time of death, and the Director of Nursing was notified, there was no confirmation or documentation that the funeral home had been contacted to remove the resident's remains. Multiple LPNs on different shifts assumed that either the hospice nurse or another staff member had made the necessary notification, but none confirmed or documented this action. As a result, the resident's body remained in the facility until the following day, when a housekeeper discovered the remains and notified nursing staff, prompting the eventual call to the funeral home. The lack of clear communication and documentation among staff members led to a significant delay in the removal of the deceased resident's body. Shift-to-shift handoffs did not include confirmation of funeral home notification, and there was no entry in the resident's chart indicating when the remains were removed. The hospice nurse had informed staff that the facility was responsible for contacting the funeral home after the family had spent time with the resident, but this responsibility was not clearly assigned or followed up on by facility staff. This breakdown in communication and documentation resulted in the resident's remains remaining in the facility for an extended period after death.
Failure to Secure Exit Door Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to ensure that an exit door was properly secured after use, resulting in the elopement of a resident. On the day of the incident, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) exited the facility through an employee service door with a keypad lock to smoke. Both staff members acknowledged that the door sometimes does not latch unless it is pulled closed, and neither could confirm if the door was properly locked when they left. Shortly after, the CNA observed the resident, who has diagnoses including dementia, Alzheimer's disease, cognitive decline, and repeated falls, in the hallway prior to their exit. Upon returning, the CNA heard knocking and found the resident outside, knocking on their room window. The resident was then brought back inside by staff. The resident later confirmed that they had followed the staff out the door and were unable to re-enter the facility after the door locked behind them. The facility's policy requires staff to be aware of residents' locations at all times and to ensure their safety, but this was not followed, as staff did not verify the door was secured and did not maintain awareness of the resident's whereabouts. The incident was reported to the facility administrator, and interviews with involved staff confirmed the sequence of events and the failure to ensure the door was locked.
Failure to Identify PTSD Triggers and Provide Resident-Centered Interventions
Penalty
Summary
The facility failed to identify potential triggers for Post-Traumatic Stress Disorder (PTSD) and did not implement resident-centered interventions for a resident admitted with a diagnosis of PTSD. Upon admission, the resident's Brief Trauma Questionnaire did not address the PTSD diagnosis or identify possible behavioral triggers, and the care plan was not updated to include interventions or triggers related to PTSD. The resident had a complex medical history, including Parkinson's Disease, COPD, Lupus, Generalized Anxiety Disorder, Major Depression, and substance dependence. Despite these diagnoses, the facility did not adequately assess or plan for the resident's PTSD-related needs. Following a conversation with the Social Service Director about possible alternative placements, the resident became suspicious and believed she was being involuntarily discharged, which was not the case. The resident subsequently experienced severe emotional distress, including a manic episode and PTSD symptoms, and was unable to be redirected or emotionally regulated by staff interventions. The situation escalated to the point where the resident attempted to leave the facility, resulting in police and emergency medical services involvement and eventual transfer to a hospital for evaluation and treatment. The lack of trauma-informed and culturally competent care contributed to the exacerbation of the resident's behavioral symptoms.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement appropriate pressure ulcer care and prevention strategies for a resident, resulting in the development of two stage two and one stage three pressure ulcers. The resident, who has severe cognitive impairment and is dependent on staff for various activities, was observed sitting in a wheelchair for extended periods without adequate pressure relief. Certified Nursing Assistants (CNAs) reported that the resident was not laid down between meals as required, and pressure relieving boots were only introduced after the development of a heel wound. The facility's documentation and communication regarding the resident's pressure ulcers were inadequate. The Wound Nurse and Wound Nurse Practitioner discovered undated dressings and were unaware of the resident's right ischium wound until the day of the assessment. The resident's care plan had not been updated to reflect the presence of pressure ulcers or new pressure relieving interventions since 2022. Additionally, the facility's electronic medical record (EMR) lacked documentation of pressure relieving interventions, and there were missing skin assessments for December 2024 and January 2025. The facility's staff failed to coordinate pain management effectively, as evidenced by the resident's expressions of pain during wound care without prior administration of pain medication. The Director of Nursing (DON) acknowledged the missing skin assessments and the lack of updates to the resident's care plan. The facility's policies on wound treatments and skin management were not followed, as pressure relieving interventions were not consistently implemented, and there was a lack of timely notification to the physician regarding new wounds.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to adequately track culture results and organisms in their infection control logs, which are essential for identifying trends and preventing outbreaks. The logs from August 2024 to January 2025 did not document culture results for wound or urinary tract infections, nor did they track bacterial organisms. This oversight was confirmed by the facility's administrator, who acknowledged that while the tracking was being done, it was not properly logged. The facility's policy requires the Infection Control Nurse or Designee to monitor infections and complete incidence reports monthly, quarterly, and annually, using laboratory records and infection control rounds. In several instances, staff failed to implement Enhanced Barrier Precautions (EBP) as required. For example, staff did not wear gowns when entering rooms with EBP signs, which indicated the need for gowns and gloves during high-contact care. In one case, a wound nurse did not perform hand hygiene or change gloves consistently during wound care, and failed to disinfect equipment used during the procedure. The Director of Nursing confirmed that EBP should be implemented for residents with pressure ulcers and urinary catheters, and that gowns and gloves should be worn for all high-contact care. Additionally, there were failures in monitoring and reporting changes in residents' conditions. One resident with a history of urinary tract infections had cloudy urine, which was noted by a nurse but not communicated effectively to the nurse practitioner, resulting in the resident being hospitalized for a UTI. The facility's policy requires that changes in a resident's condition be reported to the attending physician by licensed personnel. Despite the presence of EBP signs, staff did not consistently use personal protective equipment, such as gowns, when providing care to residents with indwelling catheters.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, potentially affecting all 92 residents. The dietary manager, identified as V3, admitted to not being a certified dietary manager and lacking any certifications. The Director of Nursing, V2, confirmed that the Registered Dietician (RD), V7, only visits the facility once a week and is not present full-time. V7 expressed concerns about the nutritional values of the menus and stated that she had offered educational services and menu writing, but these offers were not accepted by the facility. V7 also mentioned filing a formal complaint with the facility administration and the contracted dietary company, but received no response. The consulting dietary services company, represented by V24, revealed that the RD responsible for writing the menus is no longer employed with them, and there has been no collaboration with the local RD. V24 stated that their company is a software company and has not been onsite recently, leaving the facility responsible for alternative menus and compliance. The facility's policy requires the director of food and nutrition services to hold an active certified dietary manager or food service manager certification, which V3 does not possess. Additionally, V3 was unable to provide her food safety certification, further highlighting the deficiency in staffing qualifications.
Failure to Meet Therapeutic Diets and Nutritional Needs
Penalty
Summary
The facility failed to ensure that menus and menu substitutions were developed, prepared, and followed to meet residents' therapeutic diets and nutritional needs according to established national guidelines. During a lunch meal service observation, it was noted that the facility did not provide variations of items served based on therapeutic diets, and there were no smaller or larger portions served. Specifically, residents on Low Concentrated Sweets (LCS) and No Added Salt (NAS) diets received regular coleslaw and full dessert bars, contrary to their dietary requirements. Additionally, there were no fruit items served during the meal, which was inconsistent with the facility's documented menu. The Registered Dietician (RD) expressed concerns that the facility's current menu did not meet state requirements for fruit and vegetable servings, including necessary vitamins. The RD had attempted to communicate these concerns to the facility administrator and the consulting dietary company but received no response. The RD also noted that the facility's menu did not meet the required minimum national dietary standards and had filed a formal complaint. The facility's dietary staff were unaware of the necessary variations for therapeutic diets, and the recipe book used did not include recipes for low salt or low concentrated sugars. Furthermore, the facility failed to provide appropriate substitutes for menu items. For instance, a resident with severe cognitive impairment and significant weight loss was not served the pureed pears listed on their meal ticket but was instead given ice cream. The RD confirmed that ice cream was not an appropriate substitute for pears and that applesauce would have been a suitable alternative. The facility's policy on menu substitutions required that substitutes be of similar nutritive value and planned with the dietitian, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which has the potential to affect all 92 residents. During a kitchen and storage area tour, food debris was found inside the toaster, on the countertop, and on the floor. Boxes of food were improperly stacked in the food prep area, and bulk bin containers were placed in a high-traffic area. In the walk-in freezer, a bin labeled 'Meatballs' contained an unidentifiable substance with freezer burn, and the standing cooler had unlabeled and undated sliced ham and cheese. The dietary aide cooler contained uncovered and undated pudding bowls, and the dry storage had bins of oatmeal and brown sugar without expiration dates, with scoops improperly stored. During lunch meal service, food temperatures were not checked before serving, and the cold coleslaw was served at 54 degrees Fahrenheit, above the safe temperature range. The cook did not perform hand hygiene or change gloves after touching surfaces, and the dietary manager admitted that food temperatures are usually not checked during service. The facility's production sheet documented incorrect starting temperatures for food, with BBQ pork shoulder below the safe benchmark. The in-house dietician expressed serious concerns about the dietary services, noting that the consulting company managing food services had not been present recently. Further observations revealed ongoing issues with food storage and labeling. The walk-in freezer still contained the improperly stored 'Meatballs,' and the dietary aides' cooler had uncovered and undated yogurt cups. Employee drinks and unlabeled thickened lemon water were stored in the cooler, and raw meat was improperly stored in the cold storage. The facility's policies on food storage and safety were not followed, as evidenced by the lack of proper labeling, dating, and storage practices, as well as the failure to maintain food temperatures within safe ranges.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a qualified Infection Preventionist with the required training in infection prevention and control, which has the potential to affect all 92 residents. The facility's assessment indicated that an Infection Control Preventionist should be part of the staffing plan. However, the Administrator stated that the recently hired Wound Nurse/Infection Preventionist had not completed the necessary training. Prior to this hire, the Administrator and nurse managers collectively oversaw the infection prevention role, despite lacking the required training. The newly hired Infection Preventionist confirmed not having officially taken over the role and had not completed the training course, leaving the Administrator to handle infection prevention and control duties.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing about hospital transfers and did not provide a bed hold notice for four residents reviewed for hospitalizations. Specifically, the facility did not have documentation of a bed hold policy in the medical records of residents who were hospitalized, including R39, R17, R25, and R52. Interviews with the Director of Nursing (DON) revealed that the nurses were no longer completing bed hold forms at the time of hospitalization, and nothing was being sent to families. This lack of communication and documentation was confirmed by the facility's Administrator and Licensed Practical Nurse (LPN), who acknowledged that the bed hold policy was not being provided to residents' representatives. The facility's Discharge/Transfer Policy, dated August 2023, requires that written information about the bed hold policy be provided to residents and their representatives before a transfer to a hospital or therapeutic leave. However, the facility did not adhere to this policy, as evidenced by the absence of bed hold notices in the medical records and the lack of written communication with residents' representatives. The failure to provide this information was consistent across multiple instances of hospitalization for the residents reviewed, indicating a systemic issue in the facility's process for handling hospital transfers.
Failure in Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during catheter care for a resident, which could lead to potential contamination. Certified Nursing Assistants (CNAs) V33 and V34 did not wash their hands before donning gloves to provide catheter care for the resident. After completing the catheter care, they continued to handle the resident's incontinence brief, sheets, blankets, and call light with the same gloved hands, and subsequently exited the room without performing hand hygiene. Both CNAs confirmed their failure to perform hand hygiene before and after the catheter care. Additionally, the facility did not ensure that the resident's urinary catheter drainage bag was consistently covered with a dignity bag, as required by the facility's Catheter Care and Maintenance Policy. On multiple occasions, the drainage bag was observed hanging uncovered on the bed frame, visible from the hallway. This was only corrected on the third day of observation. The facility's Hand Washing Policy emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, requiring staff to wash hands before and after direct contact with residents and after removing gloves.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adhere to its Weight Management policy, resulting in a deficiency related to the care of a resident with significant weight loss. The policy mandates that all residents be weighed upon re-admission and weekly for the first four weeks, with any significant weight loss requiring physician notification and a care plan update. However, the facility did not obtain a re-admission weight for the resident within 24 hours, nor did they notify the physician or the resident's family about the significant weight loss. Additionally, there was no documented care plan addressing the resident's risk for or actual weight loss. The resident in question was diagnosed with severe protein-calorie malnutrition, muscle wasting and atrophy, dysphagia, and a low body mass index. After being discharged to the hospital and readmitted to the facility, the resident experienced a 14.5% weight loss over one month. Despite these conditions and the significant weight loss, the facility did not take the necessary steps to address the resident's nutritional needs, as confirmed by the Director of Nurses.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain privacy during wound care for a resident with severe cognitive impairment. On two separate occasions, wound care was performed without pulling the privacy curtain to block the view from the doorway and hallway, exposing the resident's buttocks and perineal area. The first incident involved a wound nurse, a wound nurse practitioner, and a CNA, who entered and exited the room without ensuring privacy. The second incident involved the Director of Nursing and a CNA, who also failed to pull the privacy curtain during the observation of the resident's wounds. The facility's policy on resident privacy and dignity requires that privacy be maintained during activities of daily living, including wound care, by closing the door and drawing the curtain.
Failure to Provide Range of Motion Services
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion for a resident, identified as R34, who was reviewed for range of motion issues. R34, who has moderate cognitive impairment and impaired range of motion in one upper and one lower extremity, was observed sitting in a wheelchair with a brace on the right leg and reported not receiving any therapy services or exercise programs since admission. The facility's MDS Coordinator confirmed that R34 had not been evaluated by therapy since transferring from another facility, and the Director of Nursing acknowledged the lack of restorative nursing services for R34. R34's care plan did not document any problems, goals, or interventions to address the impaired range of motion, and there was no record of therapy or restorative nursing services being provided. The facility's Functional Maintenance Program outlines the need for a Contracture Risk Evaluation upon admission and the implementation of custom interventions to prevent decline, but these were not applied to R34. The resident had been on antibiotics for pneumonia, which delayed the therapy screening, but the lack of restorative services was a significant oversight.
Failure to Investigate and Document Fall Incident
Penalty
Summary
The facility failed to investigate and document a fall incident involving a resident, identified as R39, who was being transported in a van. During the transport, R39 slipped out of the wheelchair due to the mechanical lift sling being improperly positioned, causing R39 to slide down in the chair. Although R39 did not hit the floor, the incident was serious enough to require assistance from the fire department and an ambulance to transport R39 to the hospital. Despite this, the Director of Nursing (DON) did not consider it a fall, did not conduct an investigation, and did not implement any new interventions at that time. Additionally, the facility failed to complete fall risk assessments for R39, as required by their policy. The last documented fall risk assessment was in 2023, and no assessments were completed in 2024, despite the occurrence of falls. The facility's policy mandates that fall risk assessments be conducted quarterly and as needed following a fall or change in condition. The lack of timely assessments and updates to R39's care plan after the incidents indicates a failure to adhere to the facility's Accidents & Incidents Policy, which requires thorough investigation and documentation of all accidents and incidents involving residents.
Improper Storage and Care of Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper hygiene and storage for respiratory equipment for two residents. For one resident, the CPAP mask was observed uncovered and improperly stored on the nightstand, contrary to the facility's guidelines which require the mask to be cleaned daily, air-dried, and stored in a plastic bag when not in use. The Licensed Practical Nurse (LPN) confirmed the improper storage and acknowledged the need to store the mask in a bag. The Director of Nursing reiterated the facility's protocol for CPAP mask care, which was not followed in this instance. Another resident's oxygen equipment was also improperly managed. The oxygen concentrator was off, and the nasal cannula was found on the floor without a storage bag. The resident's care plan did not address their COPD or the use of oxygen and nebulizer treatments, despite having a physician's order for oxygen use as needed. The LPN confirmed the absence of a storage bag and the improper placement of the nasal cannula. The Director of Nursing stated that the tubing should be stored in a bag when not in use, which was not done in this case. Additionally, the care plan coordinator confirmed the care plan's omission of the resident's respiratory needs.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to adhere to its protocol regarding the limitation of PRN psychotropic medication orders to 14 days. Specifically, a resident was prescribed Lorazepam, an antianxiety medication, on November 14, 2024, with instructions to administer 0.25 ml every 4 hours as needed for agitation or restlessness. Despite the facility's protocol requiring a reassessment by a physician after 14 days, the medication order remained active beyond this period without reassessment, as the resident had not used the medication since November 18, 2024. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the 14-day limitation for PRN psychotropic medications as per the facility's protocol.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to develop and implement effective fall interventions and safety measures for two residents, resulting in multiple falls and injuries. One resident, who had moderate cognitive impairment and was a high fall risk, experienced several falls, including two that resulted in head lacerations requiring medical attention. Despite being identified as restless and anxious, the facility did not implement new safety interventions promptly, such as fall mats or bolsters, until after the falls occurred. The resident's care plan included interventions like keeping items within reach and bringing the resident to the common area when anxious, but these measures were not effectively executed or updated in response to the resident's changing condition. The facility's investigation into the falls was inadequate, as it did not thoroughly assess potential contributing factors such as the timing of toileting or incontinence care. The resident was often found attempting to get out of bed or a chair without assistance, indicating a need for more direct supervision or alternative interventions. Staff reported the resident's restlessness and attempts to self-transfer, but there was a lack of consistent implementation of interventions to address these behaviors. Additionally, there was no documentation of pain management being considered as a factor for the resident's restlessness, despite the potential for pain to contribute to such behavior. Another resident with severe cognitive impairment and a history of falls also experienced an unwitnessed fall while attempting to self-transfer. The care plan included an intervention to offer to lay the resident down after lunch, but this was not consistently followed by staff. The facility's policy required immediate investigation and implementation of appropriate interventions following accidents, but the investigations did not adequately address the root causes or ensure that staff were re-educated on necessary fall prevention measures. These deficiencies highlight a failure to provide adequate supervision and timely interventions to prevent falls and ensure resident safety.
Failure to Report Potential Abuse Incident
Penalty
Summary
The facility failed to immediately report an allegation of potential sexual abuse involving two residents to the Abuse Coordinator and the State Surveying Agency. The incident occurred when a Certified Nursing Assistant (CNA) observed one resident, who is moderately cognitively impaired and diagnosed with schizophrenia, in the bed of another resident, who is severely cognitively impaired and dependent on staff for mobility. The CNA witnessed the resident on top of the covers, kissing the other resident on the cheek. Despite the CNA's awareness of the situation, the incident was not reported to the Administrator/Abuse Coordinator at the time it occurred. The CNA called for assistance from a Licensed Practical Nurse (LPN), who helped remove the resident from the bed. However, neither the CNA nor the LPN reported the incident to the Administrator. The Administrator only became aware of the situation the following morning during a meeting. The failure to report the incident immediately was confirmed by the Administrator, who acknowledged that staff should have reported the potential abuse incident to the Abuse Coordinator and the Department of Public Health.
Failure to Prevent Resident Fall During Bed Repositioning
Penalty
Summary
The facility failed to prevent a fall incident involving a resident, identified as R1, who sustained severe injuries including a skull fracture and brain bleed. The incident occurred when two CNAs, V3 and V4, were attending to R1 for repositioning. R1 was found lying close to the edge of the bed, and as V3 began to raise the bed, R1 became startled, pulled back the blanket, and fell to the floor. The CNAs were unable to catch R1 in time, resulting in the fall. The incident note and interviews with the CNAs revealed that R1 was not informed about the care procedure, which contributed to the resident's startled reaction and subsequent fall. R1's care plan indicated that the resident required assistance with bed mobility and could be uncooperative due to dementia and Alzheimer's disease. The care plan also emphasized the need for clear explanations of care activities to R1. The facility's policy on bed positioning required staff to explain procedures to residents before performing them. However, this protocol was not followed, as V4 admitted that R1 was not awakened or informed about the care, which likely led to the resident's startled response. The Director of Nursing confirmed that the bed's noise during elevation could have startled R1, and staff should have been positioned at the bedside to prevent falls.
Failure to Coordinate Discharge Plans and Notify Physician
Penalty
Summary
The facility failed to re-evaluate and coordinate discharge plans for a resident being discharged home, and did not notify the physician of changes in the discharge plan. The resident had stage three pressure ulcers on both heels, requiring specific wound care and pressure-relieving boots. The discharge plan did not specify if wound care would be provided by home health services or list any follow-up appointments with a wound clinic. Despite the resident's family being informed of the discharge and the setup of home health services, the resident was not accepted by any of the home health agencies contacted due to insurance issues and capacity constraints. This information was not communicated to the nurse practitioner or documented properly by the post-acute care coordinator. The resident was discharged home without the necessary home health services or a scheduled wound clinic appointment. The resident later required hospitalization and a wound clinic appointment due to the lack of proper wound care. Interviews with the staff revealed that the post-acute care coordinator failed to document the denial of home health services and did not notify the nurse practitioner, who would have recommended the resident stay in the facility longer. The director of nursing was also unaware of the denial of home health services and confirmed that proper follow-up should have been conducted and documented. The facility's discharge policy requires comprehensive discharge planning, which was not adhered to in this case.
Failure to Document and Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to conduct and thoroughly document weekly skin assessments, identify a newly reopened pressure ulcer, notify the physician, and obtain pressure ulcer treatment orders for one resident. The resident, who is cognitively intact and at risk for pressure ulcers, had a history of stage two and stage three pressure ulcers that were facility-acquired. There were significant gaps in the documentation of weekly skin assessments, with no records from 2/25/24 to 3/22/24 and then again until 4/5/24. Additionally, the wound that had healed by 4/17/24 was not documented as reopened until 4/24/24, and there was no evidence of physician notification or treatment orders during this period. On 4/30/24, the wound nurse confirmed that the resident's left buttock wound had reopened and required treatment. The Licensed Practical Nurse who conducted the skin assessment on 4/19/24 did not notify the physician or measure the wound, mistakenly believing it was not a new wound. The Director of Nursing confirmed the lack of documentation for weekly skin assessments and wound assessments/measurements. The facility's Skin Condition Monitoring policy mandates weekly skin assessments and physician notification for new wounds, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paxton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Paxton Senior Living | 0.7 mi | ★★★★★ | 2 | 0 |
| Country Health | 11 mi | ★★★★★ | 23 | 0 |
| Goldwater Care Gibson City | 14.9 mi | ★★★★★ | 12 | 0 |
| Gibson Community Hsp Annex | 15.1 mi | ★★★★★ | 0 | 0 |
| Gilman Healthcare Center | 20.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.