Accolade HC of Paxton: Heel Wound Misdiagnosis - IL
That was the extent of his answer.
The resident, identified in inspection records only as R2, had developed injuries on both heels. The wound care physician's assistant, identified as V9, conducted an initial exam on August 19, 2025, and classified both wounds as Stage 2 pressure ulcers. The right heel wound measured one centimeter long, half a centimeter wide, and a tenth of a centimeter deep. The left was larger: three centimeters long, one and a half centimeters wide, the same depth.
The facility's own wound nurse, V7, had reached a different conclusion. Her assessment classified the same wounds as Deep Tissue Injuries, a distinct and more serious classification. Stage 2 pressure ulcers involve a partial-thickness loss of skin. Deep Tissue Injuries are characterized by intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration — the tissue underneath has been damaged, but the surface may still be closed.
On August 26, the day before the inspection concluded, V7 removed the foam border dressings from R2's heels so inspectors could observe the wounds directly. What they saw was consistent with V7's assessment, not V9's. R2's left heel had a half-dollar-sized purple intact Deep Tissue Injury. The right heel had a dime-sized purple Deep Tissue Injury. R2 denied pain.
V9's August 19 document also contained a second error. It listed the wound acquisition date as August 10. The facility's own records showed the wounds were identified on August 13. Three days is not a rounding difference in wound care documentation — the acquisition date shapes how a wound's progression is tracked and whether its development is considered preventable.
The treatment order V9 wrote compounded the problem. His August 19 document specified that the wounds should be cleansed with 0.125% Dakin's solution, a sodium hypochlorite preparation sometimes used for infected or heavily contaminated wounds. The actual order being carried out at the facility called for wound cleanser, skin prep, and a foam border dressing. V7 told inspectors on August 26 that Dakin's solution is not something you would use on intact skin. V9, when confronted with the discrepancy that same afternoon, agreed. He verified that Dakin's solution would not be used for intact skin.
He did not explain how the order came to be written that way.
When inspectors pressed V9 on the staging error, asking why his assessment had classified both wounds as Stage 2 pressure injuries when the facility's own wound nurse had documented them as Deep Tissue Injuries, he said he believed he had documented that by mistake. He offered nothing further. When asked what wound care experience or certification he held, he said he had been a physician's assistant for a long time. Inspectors noted he did not indicate any specialized wound care experience or certification.
CMS rated the deficiency as causing actual harm to residents.
R2, for the duration of this period, had wounds that were misclassified in the specialist's records, logged with the wrong start date, and paired with a treatment order calling for a solution the specialist himself ultimately acknowledged was inappropriate for the type of wound present. The foam dressings were in place. The wounds, when observed, were closed and intact. R2 said they did not hurt.
What the record contained, and what was actually happening, were not the same thing. The person responsible for reconciling that gap told inspectors he had been doing his job for a long time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accolade Hc of Paxton On Pells from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
ACCOLADE HC OF PAXTON ON PELLS in PAXTON, IL was cited for violations during a health inspection on August 27, 2025.
That was the extent of his answer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.