Nexus Pavilion at Belleville: Resident Abuse Violation - IL

Federal inspectors cited Nexus Pavilion at Belleville for abuse causing actual harm to a resident, following a complaint inspection conducted October 16, 2025. The citation documents a physical altercation on October 6 between a CNA identified in the report as V14 and a resident identified as R3, an account pieced together from interviews with the CNA, a charge nurse, a facility visitor, and the facility's President of Clinical Operations.

The visitor, identified as V18, told inspectors she was "shocked and confused" by what she found. R3's account, V18 said, never changed no matter how many times she asked her. R3 seemed alert and oriented. V18 said the only explanation the CNA offered was that she didn't touch R3, she just moved the chair, that she didn't do anything to her. R3 showed V18 a rubber bracelet R3 said was ripped off during the fight. It was ripped.

The police showed up.

The CNA's account, given to inspectors on October 6 at 2:49 in the afternoon, began with a chair in the hallway. V14 said she had been sitting outside R3's room when R3, who V14 said told her she used to be a nurse, began yelling at her. According to V14, R3 called her a bitch and a whore and told her she wasn't sitting down, that she was going to work. V14 said she got up to answer a call light. When she came back, the chair was gone.

V14 said she went into R3's room to retrieve it. She grabbed the chair and started pulling it out. R3, she said, was trying to get to her and threw water at her. V14 kept pulling the chair. R3 fell.

"She fell in slow motion," V14 told inspectors. V14 said she didn't hit R3. "If anything, she hit herself." As for the black eye, V14 said she didn't know how R3 got it. She suggested R3 may have slipped in the water on the floor.

The charge nurse, an LPN identified as V10, was interviewed two days later, on October 8. She said she was called to the room and found R3 lying on the floor. R3 told her V14 had hit her. R3 complained of pain to her left eye. V10 noted that she works at the facility from time to time and that V14 knew who she was and recalled their last interaction. R3, V10 said, has behaviors, but R3 was alert and oriented.

The facility's President of Clinical Operations, identified in the report as V4, spoke with inspectors on October 6 at 3:25 in the afternoon. She said she had shown up the night before after being notified of the incident right away. She had not finished her investigation.

V4 offered a theory: R3 might have fallen on the chair to get the injury to her eye. She said she thinks the CNA might have argued when she shouldn't have with R3, but she still hadn't completed the investigation. Her understanding, she said, was that the CNA went into the room to get the chair, R3 threw water at her, and when the CNA pulled the chair, R3 went after it and might have slipped on the water trying to grab it.

Then V4 added: R3 told her the CNA punched her.

That detail, delivered in the same breath as the slipping-on-water theory, sits at the center of what inspectors found troubling enough to cite as actual harm. A resident, described by multiple staff as alert and oriented, reported being punched. She had a black eye. She had pain. She was found on the floor. Her bracelet was ripped. The CNA who was alone with her when she fell said she didn't know how the injury happened.

The inspection report does not document that the facility had suspended the CNA pending the outcome of the investigation, or that the investigation had been completed before inspectors arrived ten days after the incident. What it documents is an administrator who, two days after a resident was found on the floor with a black eye, was still working through what she thought might have occurred.

The facility's own abuse policy, dated September 2017, states that the facility affirms the right of residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment. The policy says the facility prohibits all of it and that the purpose of the policy is to assure the facility is doing all within its control to prevent occurrences.

What the inspection record shows is a resident who told every person who asked her, including a visitor, a charge nurse, and the facility's top clinical officer, that a staff member hit her. Her account, according to the visitor, never changed. The CNA's explanation shifted between not touching R3 at all and not being sure how she fell, with a suggestion that R3 may have slipped in water the CNA herself had watched R3 throw.

V4 told inspectors R3 has been cycling lately, a reference to behavioral patterns. She mentioned coming to the facility over the weekend to find R3's room destroyed at one point. The report does not indicate that R3's behavioral history was used to explain away her account, but the sequencing of V4's interview, moving from R3's behaviors to the incomplete investigation to R3's statement that the CNA punched her, is the sequence inspectors recorded.

The CNA said R3 was agitated all day, calling her bitches and whores. That may be true. It is also true that a resident who calls staff names is still entitled, under the facility's own written policy and under federal standards, to be free from physical harm. The two things are not in conflict.

R3 was on the floor. She had a black eye. She had pain. She said she was punched. The bracelet on her wrist was ripped. The person who was with her when she fell said she didn't know how the injury happened.

The visitor, V18, said she was shocked and confused. She said R3's story never changed.

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.

Additional Resources

• View all inspection reports for Nexus Pavilion At Belleville
• Browse all IL nursing home inspections