Nexus at Palos: Undetected Hip Fracture, Missed Pain Reports - IL
The resident, identified in inspection records as R3, rated her pain at a 5 out of 10 in her right lower extremity. Progress notes from December 22, 2025 show staff received her in bed with no signs of distress. When family arrived with concerns and asked that she be sent to the hospital, an ambulance was called. She left by stretcher at 2:40 that afternoon.
At the hospital, she was found to have a superolateral displaced right femoral neck fracture. She told hospital staff she thought she may have fallen two weeks earlier. Her daughter said the last time she saw her mother walking was four weeks before.
The fracture had likely gone undetected the entire time.
The APRN who treated R3 during her stay at the facility told inspectors on May 27, 2026 that he never received any notification of pain in her right leg or any inability to ambulate. "If he was notified of the pain or changes to her leg," inspectors recorded, "he would have done a thorough assessment of R3's leg and probably would have ordered an x-ray." The nurse practitioner said the same thing. So did the Director of Nursing, who confirmed that pain complaints should trigger notification to a physician or nurse practitioner, and that nurses are expected to document any interventions.
None of that happened. R3's progress notes contain no record of any notification to a doctor or nurse practitioner about her pain or the changes to her right leg.
The facility's own pain management policy, reviewed in October 2025, states that licensed nursing may notify the healthcare provider of any new or changing pain. Its change-in-condition policy, updated in September 2025, requires nursing to notify the physician or nurse practitioner of significant changes in a resident's physical status and to document that communication.
R3 left the facility with a broken hip. The x-ray that might have caught it weeks earlier was never ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Palos from 2026-05-29 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 19, 2026 · Our methodology
Nexus at Palos in PALOS HILLS, IL was cited for violations during a health inspection on May 29, 2026.
The resident, identified in inspection records as R3, rated her pain at a 5 out of 10 in her right lower extremity.
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.