Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accolade Paxton Senior Living during CMS and state inspections, most recent first.
Multiple residents reported waiting up to or over an hour for call lights to be answered, especially at night, despite a facility policy requiring timely and courteous responses. Surveyors observed that the call light system lacked an audible alarm and lights above room doors, relying only on visual banners and a computer panel that were not consistently monitored by staff. Cognitively intact residents who required staff assistance for toileting described frequent delays that led to wet bedding and the need for linen changes. In addition, residents reported that CNAs, including agency staff, spoke to them in a rude or dismissive manner, told a resident to go to the bathroom independently despite documented need for substantial assistance, and stated that a resident would have to wait for help while they attended to another call light. Resident council minutes and grievance forms reflected ongoing concerns about delayed call light response and disrespectful attitudes from agency staff.
Medication containers were not properly labeled with opening dates for eye drops and an inhaler for three residents. During cart inspection, open Latanoprost bottles, an Incruse Ellipta inhaler, and additional Latanoprost and Timolol containers were found without documented dates of opening, despite active orders on the MARs and facility policy requiring proper medication labeling.
A resident admitted after treatment for severe shoulder pain had a hospital discharge order for Methocarbamol 500 mg PO every six hours for a set number of doses, but the admission RN entered the medication on the MAR as PRN instead of scheduled, with no documentation of an authorized change. The MAR showed only one dose given and recorded ongoing pain scores, while the care plan called for administering pain medication as ordered and documenting effectiveness. The resident did not recall requesting any change to the order, and the DON later identified the discrepancy as a transcription error, with no supporting documentation in the medical record.
A facility failed to ensure POLST status matched resident wishes in the EHR for two residents. One resident's records conflicted between Full Code documentation and a POLST marked DNR, while another resident's EHR showed DNR on a POLST that lacked the resident's or representative's signature and was signed only by an unknown hospital nurse. Care plans and other EHR entries also conflicted with the POLST information, and staff noted difficulty clarifying one resident's preferences due to severe cognitive impairment.
The facility failed to complete discharge MDS assessments for two residents who had been discharged. The MDS RN stated she missed both discharge MDSs and said she usually completes them immediately.
A resident recently admitted after shoulder surgery had repeated falls related to attempts to stand or self-transfer from a wheelchair. Staff documented unlocked wheelchair brakes, an anti-rollback device, a fall mat, frequent rounding, room relocation near the nurse’s station, and wheelchair adjustment, but the care plan was not revised to include the falls or the post-fall interventions.
Failure to Respond Timely to Call Lights and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were answered within a reasonable time frame and that residents were treated with dignity and respect. Facility policy required call lights to be answered in a reasonable time and courteously, yet multiple residents reported waiting up to or over an hour for assistance, particularly at night. Resident council minutes over several months documented ongoing concerns about delayed call light response times, and a grievance form recorded residents’ feelings that they did not receive enough support on nights. Observations by surveyors showed that the call light system had no audible alarm or lights above resident doors, with alerts only displayed on a scrolling banner at the end of hallways and on a computer screen at the nurses’ station. At several observed times, the banner showed active call lights for multiple residents while no staff were present monitoring the panel. Several cognitively intact residents who required staff assistance for toileting or hygiene reported long waits for help after activating their call lights. One resident’s representative stated the resident had to wait an hour for a CNA to answer the call light to use the bathroom. Two other residents stated they sometimes waited over an hour for call lights to be answered, more often at night, and another resident reported that it could take an hour for staff to respond when needing to use the bathroom. One resident, who needed substantial/maximal assistance for toileting hygiene and was documented as always continent of bladder, reported calling for assistance with a urinal in the early morning hours and often waiting over an hour, resulting in wet bedding and the need for linen changes. Staff interviews confirmed that the call light alerts were difficult to see, there was no sound component, and there were no lights above resident doors, which contributed to staff not consistently noticing active call lights. The facility also failed to ensure residents were consistently treated with dignity and respect in their interactions with staff. One cognitively intact resident reported that a CNA, identified as working that resident’s hallway, responded in a rude and “smart” manner when questioned about delayed assistance and told the resident he should be going to the bathroom independently, despite documentation that the resident required substantial/maximal assistance for toileting hygiene and had arthritis in his hands affecting his ability to hold a urinal. Another cognitively intact resident and that resident’s roommate reported that a night-shift agency CNA spoke rudely, talked down to the resident, and told the resident they would have to wait for assistance because the CNA was there to answer the roommate’s call light, which led to an argument. Resident council minutes and grievance forms documented prior concerns about agency staff having “mouthy” attitudes and not always identifying themselves, and identified the same agency CNA as having been assigned to the hallway where the reported rude interaction occurred.
Medication containers lacked opening dates
Penalty
Summary
The facility failed to appropriately label eye drops and inhalers with the date opened for three residents reviewed for medication administration. During an inspection of the Main Skilled Medication Cart with the RN, two open bottles of Latanoprost for one resident were found without documented dates of opening. Another resident’s Incruse Ellipta inhaler also lacked a documented date of opening, and a third resident’s Latanoprost and Timolol did not contain documented dates of opening. Review of the MARs showed that the three residents had active physician’s orders and were currently receiving these medications: Latanoprost ophthalmic solution for one resident, Incruse Ellipta inhalation aerosol powder for another resident, and Latanoprost ophthalmic solution plus Timolol maleate ophthalmic solution for the third resident. The FDA-approved package inserts for Latanoprost and Incruse Ellipta specify opening and discard dating instructions, and the RN stated that multi-dose containers must be labeled with the date of opening and that the nurse who initially opens the container is responsible for documenting it. The facility’s medication labeling policy also states that medications must be properly labeled in accordance with current state and federal requirements, and that the Charge Nurse is responsible for ensuring proper labeling.
Transcription Error in Pain Medication Order Leading to Inadequate Implementation
Penalty
Summary
The deficiency involves a failure to accurately transcribe and implement a hospital discharge order for pain management medication for one resident. The resident was admitted from the hospital after treatment for severe left shoulder pain and reported that the pain returned, leading to rehospitalization five days after admission. The hospital discharge orders dated 3/9/26 directed Methocarbamol 500 mg by mouth every six hours for 15 doses. However, the March 2026 MAR listed Methocarbamol 500 mg by mouth every six hours as needed (PRN) from 3/9/26–3/16/26, with only one dose administered, and did not include the scheduled order for every six hours for 15 doses. The MAR documented the resident’s pain scores as 3, 8, and 5 on subsequent days, and the active care plan identified actual/potential pain with an intervention to give medication as ordered and document effectiveness. The resident stated he did not recall taking Methocarbamol or requesting that the order be changed from scheduled to PRN. The medical record contained no documentation explaining any change to the Methocarbamol order. The admissions RN, who reviews and enters admission orders with the NP or physician, confirmed on review of the hospital discharge orders that Methocarbamol was ordered every six hours, but acknowledged entering it as PRN instead of scheduled and was unsure why this occurred. The DON stated that the Methocarbamol order discrepancy was a transcription error, and there was no documentation in the record to support an authorized change in the order.
POLST and Code Status Not Consistently Reflected in EHR
Penalty
Summary
The facility failed to ensure POLST status reflected resident wishes in the Electronic Health Record for two residents reviewed for advance directives. For one resident, the admission record, Order Detail Report, and Resident Information Sheet documented Full Code, while the Illinois POLST form had an X marked for Do Not Attempt Resuscitation and was signed by the resident and the authorized practitioner. The care plan was revised to note that the resident chose death with dignity and that the individual wishes included DNR refer to POLST. A registered nurse verified that the facility would refer to the code status listed on the Resident Information Sheet in the EHR. For another resident, the EHR banner alert documented DNR: refer to POLST, but the referenced POLST identified the resident as DNR without the resident's signature or the resident representative's signature. The form stated it was signed only by an unknown hospital nurse indicating verbal consent, but it did not identify who gave that consent. The care plan documented Full Code and that the resident chose death with dignity with advance directives established. The social services director documented unsuccessful attempts to clarify the resident's preferences using the resident's preferred communication method, and noted severe cognitive impairment during the interaction. The DON stated the code status change should have been addressed in the care plan at readmission, and also stated the hospital had been returning POLST forms signed only by nursing staff without identifying the consenting party, with no follow-up to verify with the resident or POA.
Missed Discharge MDS Assessments for Two Residents
Penalty
Summary
The facility failed to submit discharge MDS resident assessments for two residents reviewed for resident assessment. R20 had an admission date of 11/12/25 and a discharge date of 12/27/25, but the MDS list showed no discharge MDS completed. R54 had an admission date of 11/06/25 and a discharge date of 12/11/25, but the MDS list also showed no discharge MDS completed. On 04/08/2026 at 11:22 AM, the MDS RN stated she did in fact miss doing the discharge MDS for both residents and said she usually completes the discharge MDS immediately.
Care Plan Not Updated After Repeated Falls
Penalty
Summary
The facility failed to revise R82’s care plan to include falls and post-fall interventions after admission. R82 was recently admitted following shoulder surgery and had a right humerus fracture. On 3/29/26, R82 fell after attempting to stand from the wheelchair to look for clothing in the closet. The interdisciplinary note on 3/30/26 documented that the wheelchair brakes were not locked at the time of the fall and identified the root cause as R82 standing by herself in combination with unlocked wheelchair brakes. An anti-rollback device was added to the wheelchair, and a fall mat was placed at the bedside, with the care plan noted as updated to reflect these changes. R82 fell again on 4/4/26 after attempting to self-transfer from the wheelchair, and a CNA found R82 on the floor of the room. The interdisciplinary team note on 4/5/26 documented frequent rounding and moving the room closer to the nurse’s station, and the note on 4/7/26 documented therapy adjusted the wheelchair by lowering the seat height and removed the anti-rollback device. The care plan dated 3/27/26 still only identified R82 as at risk for falls, admitted on [DATE], and having a right humerus fracture, and it had not been revised to include the falls or the post-fall interventions. The ADON and Administrator confirmed the care plan had not been updated with these events and interventions.
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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.
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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 Hc Of Paxton On Pells | 0.7 mi | ★★★★★ | 7 | 0 |
| Country Health | 10.7 mi | ★★★★★ | 10 | 0 |
| Goldwater Care Gibson City | 14.4 mi | ★★★★★ | 11 | 0 |
| Gibson Community Hsp Annex | 14.6 mi | ★★★★★ | 0 | 0 |
| Gilman Healthcare Center | 21 mi | ★★★★★ | 0 | 0 |
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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 August 2026) and official state health department websites.