Nexus at Palos: Fall Causes Scalp Hematoma - IL
The August 7 incident at Nexus at Palos involved a resident with end-stage renal disease who had been classified as requiring two-person assistance at all times for turning and repositioning. The patient's fall risk score of 10 placed them in the facility's high-risk category, according to the nursing home's own fall prevention policy.
During the incident, Director of Nursing V2 was assisting certified nursing assistant V19 with the resident's care when she stepped away to move a garbage can. At that moment, V19 wiped the resident, causing them to jerk and start sliding off the bed. V2 was unable to return in time to prevent the fall.
"V2 said she stepped away from the resident to move or get the garbage can at the same time V19 (CNA) wiped R4 causing her to jerk and start to slide off the bed," federal inspectors documented after interviewing both staff members in September. "V2 said she was unable to stop R4 from falling."
The resident, identified in inspection records as R4, had been admitted with weakness and difficulty walking. Their functional assessment indicated they required "substantial/maximal assistance" with toileting and hygiene, meaning staff had to provide more than half the effort for basic care.
V19 told inspectors the resident "is total care and requires two people for all care." The nursing assistant said the resident was on their side during cleaning when the director of nursing "went to get the garbage can by the door when R4 starting to go forward because she could hold her weight."
The facility's own task list from July 30 explicitly documented that the resident required "two person assist at all times" for turning and repositioning.
After the fall, staff conducted a head-to-toe assessment and found no deformities or complaints of pain initially. However, they noted "lump to left frontal lobe" and administered pain medication before applying an ice pack to the resident's head. The doctor and nurse were notified, and new orders were written to send the patient to the hospital for evaluation and treatment.
Hospital discharge paperwork from August 7 confirmed the resident had sustained a scalp hematoma from the fall.
The facility's restorative nurse, V16, told inspectors that staff "should never leave the bedside when providing care and all items should be at bedside prior." V16 emphasized that "staff should have never left the resident bedside during care."
Following the incident, V16 provided reeducation to staff about ensuring all necessary items are positioned at the bedside before beginning care procedures.
The violation represents what federal inspectors classified as "actual harm" to the resident. Nexus at Palos is disputing the citation, according to inspection records.
The incident highlights the critical importance of maintaining two-person assistance protocols for high-risk residents. Federal regulations require nursing homes to provide adequate supervision to prevent accidents and ensure areas are free from hazards that could cause harm to residents.
For residents classified as high fall risk with scores of 10 or greater, the facility's own policy mandated enhanced safety measures. The resident's functional assessment had clearly documented their need for maximal assistance with basic care activities, including the type of incontinence care being provided when the fall occurred.
The timing of staff movements during care procedures proved crucial in this case. The brief moment when both caregivers were not positioned to provide immediate support created the conditions that led to the resident's injury and subsequent hospitalization.
Staff used a mechanical lift and two-person assistance to reposition the resident back in bed after the fall, demonstrating they understood the proper protocols for safe handling but had failed to maintain them during the care procedure that preceded the accident.
The incident occurred despite the presence of the director of nursing, indicating that even experienced staff can make critical errors in judgment when proper safety protocols are not consistently followed during resident care activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Palos from 2025-09-05 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: June 20, 2026 · Our methodology
Nexus at Palos in PALOS HILLS, IL was cited for violations during a health inspection on September 5, 2025.
The patient's fall risk score of 10 placed them in the facility's high-risk category, according to the nursing home's own fall prevention policy.
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.