Nexus at Alton: Medication Supply Failures Cause Actual Harm - IL
The woman, identified in federal inspection records only as R3, has a list of diagnoses that fills several lines: cerebral infarction, Type 2 diabetes, COPD, hypokalemia, anemia, a coagulation defect, hypothyroidism, hyperlipidemia, anxiety disorder, obstructive sleep apnea, hypertension, mitral valve insufficiency, generalized osteoarthritis, and depression. She is cognitively intact. She depends on staff and a mechanical lift to move between her bed and her wheelchair. She knew what medication she was supposed to be getting and when.
Her physician had ordered Ozempic, a semaglutide injection used to manage blood sugar in Type 2 diabetics, every Thursday. The order had been in place since October 16. Each pen was supposed to last 28 days and deliver four doses.
On November 6, the date of her second scheduled injection under that order, a nurse documented at 5:35 in the afternoon that the medication was "not in." The medication administration record logged the dose that evening as "other/see nurse's note." When inspectors interviewed R3 on November 17, she said she had not been receiving her Ozempic every week as ordered. She said the nurses told her they couldn't find it when she asked.
The inspection report does not document that anyone at the facility contacted the pharmacy to obtain the medication, escalated the shortage to a physician, or told R3 when she could expect to receive it.
The administrator, interviewed on November 19, said she expects residents to receive their medications as ordered.
A second resident, R1, ran out of Lyrica while living at the facility. Lyrica is prescribed for nerve pain, among other conditions. An incident report dated November 15 at 6:15 in the morning, written by a nurse, documented that the floor nurse had reported R1's Lyrica was out of stock. The report stated that R1 was assessed for pain, voiced no complaints, and that a physician had been notified and given a new order to place the medication on hold until it arrived from the pharmacy.
That account did not hold up.
A nurse practitioner, interviewed on November 19, said she had checked the physician notification records for R1 and found nothing. No documentation that a physician or on-call clinician had been notified. No order placing the Lyrica on hold. R1's progress notes contained nothing about the incident at all.
The incident report said it happened. The clinical record said it didn't. Someone wrote that a doctor was called. The nurse practitioner found no evidence that anyone was.
Federal inspectors rated the medication failures as causing actual harm to a few residents. The deficiency was cited under F0755, which covers pharmaceutical services and the obligation to provide medications as ordered.
The facility's own pharmacy services policy, dated September 2017, states that pharmaceutical services are available to ensure residents receive their medications and biologicals as ordered, and that pharmacy services are provided on a 24-hour basis. The policy lists the director of nursing and the administrator as the responsible parties for ensuring those services are monitored.
What the policy says and what R3 experienced are not the same thing. She is cognitively intact. She knew her injection schedule. She asked about it. She was told, more than once, that her medication could not be found.
The inspection was conducted on November 19, 2025, following a complaint.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Alton from 2025-11-19 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 Alton in ALTON, IL was cited for violations during a health inspection on November 19, 2025.
She depends on staff and a mechanical lift to move between her bed and her wheelchair.
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.