Nexus Pavilion at Belleville: Abuse Complaint - IL
The incident unfolded when a certified nursing assistant, identified in inspection records as V14, went into the room of a resident identified as R3 to retrieve a chair. What happened next is disputed. What is not disputed is that R3 ended up on the floor, in pain, with bruising around her left eye, telling staff that V14 had hit her.
V14 told investigators she went into the room to get the chair and R3 became agitated. V14 said R3 threw water at her. V14 said she kept pulling the chair toward the door. V14 said R3 fell, but she wasn't sure how, maybe because R3 slipped in the water that was now on the floor. V14 described R3 going down in slow motion. V14 said she didn't hit R3. "If anything, she hit herself," V14 told investigators. As for the black eye, V14 said she doesn't know how R3 got it.
A licensed practical nurse, identified as V10, was called to the room and found R3 lying on the floor. V10 documented that R3 complained of pain to her left eye. V10 also documented what R3 said: that V14 had hit her.
R3 was alert and oriented at the time. V10 noted that V14 knew who R3 was and was aware of their prior interactions. V14 herself acknowledged that R3 has behavioral episodes but confirmed R3 was alert and oriented when the incident occurred.
The facility's President of Clinical Operations, identified in records as V4, told inspectors she was notified of the incident right away and came to the facility that night. She offered her own reconstruction of what might have happened. V4 said R3 might have fallen on the chair, which could account for the eye injury. She said she thought the CNA "might have argued when she shouldn't have" with R3. She said R3 had been cycling lately, and that V4 herself had come in over the weekend and found R3's room destroyed at one point. She said R3 told her directly that the CNA had punched her.
V4 said this on October 6, 2025, three days after the incident. She had not finished the investigation.
Two days after that, on October 8, inspectors were still documenting the case. The investigation, by V4's own account, remained incomplete.
What the inspection report captures is a facility still working out what happened to a resident who was lying on the floor with a black eye, whose account of events, offered while alert and oriented, was that she had been struck. The nursing assistant's account offered no explanation for the injury. The clinical operations president's account was conditional, speculative, and unfinished.
The inspection was classified as a complaint investigation. The level of harm was documented as actual harm.
There is a version of events in which R3, agitated and throwing water, slipped on the wet floor while trying to hold onto the chair being removed from her room, and struck her eye on the chair as she went down. V4 raised this possibility. V14 raised the possibility of slipping in the water. Neither could explain the black eye with certainty.
There is another version, the one R3 told to V10 from the floor and told to V4 afterward: that V14 hit her.
The facility's abuse policy, dated September 2017, states that residents have the right to be free from abuse, neglect, exploitation, and mistreatment, and that the facility prohibits all of it. The policy describes the facility's commitment to a "resident sensitive and resident secure environment."
R3 was on the floor with a black eye. Nobody in the building could say how she got it.
V14's account has a notable gap at its center. She described the sequence of events in detail: she came for the chair, R3 threw water, she pulled the chair toward the door, R3 fell. She described the fall as happening in slow motion. She said she did not hit R3. And then, on the question of the black eye, she said she doesn't know.
A fall in slow motion, witnessed by the person pulling the chair, and the witness cannot account for the most visible injury the resident sustained.
V4, for her part, was willing to say the CNA had probably argued when she shouldn't have. She was willing to say R3 might have fallen on the chair. She was not willing, at least not by October 6, to say what had actually happened, because she told inspectors she hadn't finished the investigation yet.
The inspection record does not indicate when or whether that investigation was completed, what conclusions it reached, or what, if any, action was taken against V14.
What the record shows is that a resident who was alert and oriented told two separate people, on the same night, that a nursing assistant had hit her. One of those people was a nurse who documented the complaint contemporaneously. The other was the facility's president of clinical operations, who came in that night specifically because of the incident.
R3 had behavioral episodes. V4 noted this. V14 noted this. The inspection record notes that R3 had been "cycling" and that her room had been found destroyed on a prior occasion. None of that changes what V10 documented: R3 was alert and oriented when she made the allegation. Her cognitive state at the moment of the incident and its aftermath was not in question.
The water on the floor, the chair being pulled toward the door, the fall in slow motion, the black eye with no explanation. Those are the facts the inspection report contains. The investigation that was supposed to sort them out was still unfinished three days after R3 hit the floor.
Federal inspectors documented the incident as causing actual harm to a resident. The complaint that triggered the inspection, the allegation of abuse, came from inside the building, from a resident who was conscious, oriented, and in pain, lying on the floor of her own room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus Pavilion At Belleville from 2025-10-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
Nexus Pavilion at Belleville in BELLEVILLE, IL was cited for abuse-related violations during a health inspection on October 16, 2025.
What happened next is disputed.
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.