Nexus At Alton

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide clean linens for 1 of 11 residents (Resident R4) reviewed for linens in the sample of 20.Findings include:Resident R4 admission record, print date of 9/17/25, documents Resident R4 was admitted [DATE REDACTED] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy Status.Resident R4's Minimum Data Set, dated [DATE REDACTED] documents Resident R4 is cognitively intact, dependent

on staff for activities of daily living, and mobility.On 9/16/25 at 12:00 PM, Resident R4 is lying in bed. Resident R4's pillowcase is soiled with a large brown stain.On 9/17/25 at 1:51 PM, Resident R4's pillowcase remains with the large brown stain that was observed on 9/16/25 at 12:00 PM. On the right quarter side rail there is a white towel with dried green, brown stains on it.On 9/24/25 at 9:01 AM, V2, Director of Nurses, stated linens should be changed when dirty.On 9/29/25 at 11:19 AM, V1, Administrator, stated, I am not sure where the linen policy is, but I expect dirty linens to be changed no matter what.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Alton

3523 Wickenhauser Alton, IL 62002

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent Urinary Tract Infections for 2 of 3 residents (Resident R7, Resident R13) reviewed for incontinent care in the sample of 20.Findings include:1. Resident R7's admission record, print date of 9/25/25, documents Resident R7 was admitted on [DATE REDACTED] and has diagnoses of Chronic Obstructive Pulmonary Disease and Diabetes.Resident R7's Minimum Data Set, dated [DATE REDACTED], documents that Resident R7 is severely cognitively impaired, dependent on staff for toileting, and is always incontinent of bowel and bladder. On 9/25/25 at 9:11 AM, V19, Certified Nurse Aide (CNA) removed Resident R7's incontinent brief. The brief was soiled with urine and feces. Resident R7 with pre-moistened periwash cloths cleansed, the groins, labia, perivaginal area, rolled Resident R7 over onto her side, cleansed the rectal are with multiple cloths, placed a new incontinent brief, had Resident R7 roll to her back, and then roll to the right to cleanse

the right buttock, roll to her back and then fastened the incontinent brief. On 9/25/25 at 9:15 AM, V19 stated

she missed the left buttock because she was nervous.2. On 9/17/25 at 2:15 PM, V12, CNA removed Resident R13's incontinent brief. The brief was soiled with urine. With a wet soapy washcloth, V12 wiped Resident R13's groins, labia, meatus, rectal area, and left buttocks. V12 used the same portion of the washcloth, did not cleanse

the right buttocks, and did not dry Resident R13 before putting on a new incontinent brief.Resident R13's Face Sheet, print date of 9/25, documents Resident R13 was admitted on [DATE REDACTED] and has a diagnosis of Congestive Heart Failure.Resident R13's MDS, dated [DATE REDACTED], documents Resident R13 is cognitively intact, requires supervision touching assistance with toileting, and is always incontinent of bowel and bladder.On 9/24/25 at 9:05 AM, V2, Director of Nurses, stated staff should be doing complete incontinent care. Staff should have multiple towels so when you clean a dirty area you get a new towel and clean again. You need towels for rinsing and drying also. The incontinent care policy, dated 1/25, documents, 2. Perform hand hygiene and don gloves. It continues, 5. Clean peri area with appropriate cleanser and dry. Appropriate cleanser can mean soap and water, periwash, etc. Cleansing should always be from front to back. 6. If resident needs more cleansing than above, a bath or shower may be given,' It continues, 11. Perform hand hygiene.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Alton

3523 Wickenhauser Alton, IL 62002

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

arrange contents on the sterile field. It continues, G. With clean hand, remove the inner cannula. 1. For disposable cannula, insert new inner cannula and lock into place; maintain sterility. 2. For reusable cannula, reapply tracheostomy collar over outer cannula to provide oxygenation during cleaning; cleanse secretions from outside and inside of inner cannula and rinse in sterile saline; gently reinsert cannula and lock into place; maintain sterility. H. Cleanse stoma site. 1 With sterile hand, moisten applicators or gauze with sterile and cleanse around stoma site and flange of outer cannula. 2. Assess for signs of infection, dry with sterile gauze. 3. Place new drain sponge under tracheostomy flange. I. Replace ties as needed. 1. For Velcro ties, with assistance, remove old Velcro tie, replace tie, and fasten Velcro securely.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Alton

3523 Wickenhauser Alton, IL 62002

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to provide Physician prescribed medication for 2 of 7 (Resident R2, Resident R9) reviewed for medications in the sample of 20. This failure resulted in Resident R9 missing 6 doses of pain medication leaving her in pain.Findings include:1. On 9/17/25 at 10:00 AM, Resident R9 stated I ran out of my pain medication oxy (oxycodone). I went for 3 days without pain medication. I wanted to cut my leg off it hurt so bad. I take it for my phantom pain in my right leg and the wound infection in my left leg. I don't know why I ran out either

they didn't reorder it, or pharmacy didn't deliver it.Resident R9's Minimum Data Set, dated [DATE REDACTED], documents Resident R9 is cognitively intact.On 9/25/25 at 1:47 PM, V4 LPN, stated Resident R9 did run out of her oxycodone. Her prescription had run out, and I think she was changing providers or something. Resident R9's Physician Order, dated 9/13/25, documents, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours for Pain.Resident R9's September 2025 Medication Administration Record documents Resident R9 did not receive her prescribed 5 mg of Oxycodone on 9/15/25 the 9 AM dose, 1 PM dose, 5 PM dose, 9 PM dose, 9/16/25 1 AM dose, and the 5 AM dose.2. Resident R2's Physician Order, documents, oxyCODONE HCl Oral Tablet 15 MG (Oxycodone HCl) (Oxycodone HCl) Give 7.5 mg (milligrams) by mouth six times a day for pain start date of 5/8/25.Resident R2's Nurses Note, dated 8/29/2025 06:32, documents, Call out to (pharmacy) to obtain the status of order for pain medication. Per pharmacy a quantity of 4 was ordered and 2 sent. Remaining 2 will be sent this morning. New order from MD (Medical Doctor) will be needed.Resident R2's Medication Administration Record (MAR), dated August 2025, documents Resident R2 did not receive the prescribed oxycodone 7.5 mg on 8/28/25 10 PM dose, 8/29/25 2 AM dose, and 6 AM dose.Resident R2's Minimum Data Set, dated [DATE REDACTED], documents Resident R2 is cognitively intact.On 9/16/25 at 11:27 AM, Resident R2 stated about a month or so ago I ran out of my pain medication, but it is better now.On 9/25/25 at 1:16 PM, V2, Director of Nurses stated that Resident R2 missed 3 doses of oxycodone.On 9/24/25 at 10:02 AM, V4, Licensed Practical Nurse, stated, sometimes we do run out of pain medication for the residents. I will call the doctor and get them to send over a prescription to the pharmacy if a new prescription needed to be written. If their order needs to be rewritten, you can't get the medication from the (emergency medicine dispensing machine).On 9/24/25 at 9:01 AM, V2, Director of Nurses, stated, we are in the middle of changing pharmacies. The nurses should be calling pharmacy when

the resident is down to a weeks' worth of pills. If the resident needs a new prescription, the pharmacy will call the doctor, and the doctor will send a prescription. If the resident does run out of medication, we have

the (emergency medicine dispensing machine) which the staff can pull medications from. Most narcotics are in there.The policy medication Administration, dated 4/25, documents, 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain from the contingency or convenience box. 27. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner, and a note should reflect the situation in

the resident's medical record.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Alton

3523 Wickenhauser Alton, IL 62002

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide Health Shakes for 5 of 5 residents (Resident R14, Resident R15, Resident R16, Resident R17, Resident R20) reviewed for Dietary Supplements in the sample of 20.Findings include:On 9/24/25 at 12:17 PM the dining room was entered. Resident R14, Resident R15, Resident R16, Resident R17, and Resident R20, all did not have their Physician prescribed health shake. On 9/24/25 at 12:20 PM, Resident R16 stated, They forget the shakes a lot.On 9/24/25 at 12:28 PM, V15, Dietary Manager, stated the shakes are poured up and on this cart. The aides just took the tray and didn't look at the ticket to know that resident needed a health shake.1.Resident R14's admission record, print date of 9/24/25, documents that Resident R14 was admitted on [DATE REDACTED] and has diagnoses of aphasia and Cerebrovascular disease.Resident R14's Minimum Data Set, dated [DATE REDACTED], documents Resident R14 is severely cognitively impaired and requires supervision / touching assistance with eating.Resident R14's Physician Order, dated 4/15/25, documents Diabetic shakes with meals Sugar Free. 2. Resident R15's admission record, print date of 9/24/25, document Resident R15 was admitted on [DATE REDACTED], and has diagnoses of Type 2 Diabetes and Dementia.Resident R15's MDS, dated [DATE REDACTED], documents Resident R15 is severely cognitively impaired and requires touching or supervision with eating.Resident R15's Physician Order, dated 4/15/25, documents MED PASS 2.0 with meals.3.Resident R16's admission Record, print date of 9/24/25, documents Resident R16 was admitted on [DATE REDACTED] and has diagnosis of schizoaffective disorder.Resident R16's MDS, dated [DATE REDACTED], documents Resident R16 has modified independence for decision making, requires set up clean up assistance with meals.Resident R16's Physician Order, dated 5/2/25, documents, Health Shakes in the afternoon with lunch.4.Resident R17's admission Record, print date of 9/24/25, documents Resident R17 was admitted on [DATE REDACTED] and has a diagnosis of hemiplegia and hemiparesis affecting the right dominant side after a stroke.Resident R17's MDS, dated [DATE REDACTED], documents Resident R17 is severely cognitively impaired and requires partial to moderate assistance with eating.Resident R17's Physician Order, dated 4/10/25, documents, Health Shakes with meals for supplement.5. Resident R20's admission Record, print date of 9/24/25, documents Resident R20 was admitted on [DATE REDACTED] and has a diagnosis of Alcohol Abuse with other Alcohol Induced Disorder.Resident R20's MDS, dated [DATE REDACTED], documents Resident R20 is cognitively intact and requires supervision touching assistance with eating.Resident R20's Physician Order, dated 7/24/25, documents, Health Shakes with meals.The policy Meal Service, dated 8/25, documents, 8. When the tray is delivered, the staff ensures that

the correct tray is given to the correct resident and the diet on the card matches what is on the tray.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Alton

3523 Wickenhauser Alton, IL 62002

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to wear a personal protective gown, wash hands when needed, change soiled gloves, encourage residents to wash hands, and clean multi-use equipment for 1of 5 residents (Resident R4) reviewed for infection control in the sample of 20.Findings include:1. Resident R4's Physician Orders dated 9/19/24, documents, Enhanced Barrier Precautions related to colonization for wounds, colostomy, tracheotomy.Resident R4 admission record, print date of 9/17/25, documents Resident R4 was admitted [DATE REDACTED] with diagnoses of Chronic Respiratory Failure with Hypoxia and Tracheostomy Status.On 9/17/25 at 1:51 PM, V4, Licensed Practical Nurse, entered Resident R4's room to provide tracheostomy care. V4 stated Resident R4 does the tracheostomy care himself and needs very little assistance with the care. V4 washed her hands and donned gloves. V4 opened multiple drawers gathering supplies for the care and placed them on the bedside table.

V4 changed her gloves without hand hygiene. Resident R4 removed the left tracheostomy tie and loosened the tracheostomy collar. The left side of the collar has green, brown drainage on it. Resident R4's left neck and under his neck has dried drainage on it. V4 gathered more supplies and changed her gloves without hand hygiene. Resident R4 grabbed a 4 x 4 gauze pad and dipped it in sterile saline multiple times. Resident R4 began to clean the left side of his neck and around the tracheostomy tube of the dried drainage with one 4 x 4 gauze pad. V4 removed her gloves, washed her hands, and donned sterile gloves. V4 attached the new tracheostomy tie and collar to the left side. Resident R4 took another 4 x 4 gauze pad and cleaned the right side of his neck dipping it into the sterile saline multiple times. With a 4 x4 gauze pad V4 dried Resident R4's neck and around the tracheostomy tube.

V4 removed the sterile gloves and donned non-sterile gloves without hand hygiene. Resident R4 was attempting to remove the tracheostomy collar from behind his neck. V4 with her gloved hands is touching her long hair and moving it to her back. With the same gloves, V4 assisted Resident R4 with removing the tracheostomy collar. V4 then attached the right tracheostomy tie and the tracheostomy collar. V4 changed her gloves without hand hygiene, obtained a gauze tracheostomy pad and placed it under the tracheostomy tube and collar. Resident R4 is also trying to tuck the pad. With the same gloves, V4 took a bottle of Nystatin powder and sprinkled and rubbed the powder in on his neck and upper chest. V4 removed her gloves and washed her hands. V4 left

the room to get a pulse oximetry. V4 returned and placed it on Resident R4's finger and obtained a reading of 95%.

V4 did not wear a Personal Protective Gown, provide a sterile field for supplies, did not cleanse the pulse oximetry after use, and did not encourage or offer to cleanse Resident R4's hands before, during, or after the care.On 9/24/25 at 8:59 AM, V2, Director of Nurses, stated V4 should have washed her hands, wear a gown, change gloves with hand hygiene, and follow the sterile procedure. Resident R4 should have been offered hand hygiene and not reuse gauze pads.The policy Equipment Cleaning, dated 10/24, documents, general: To provide guidance on how to clean equipment between residents. Policy: 1. Obtain bleach wipe. 2 apply gloves. 3. Take a pre-moistened disinfectant wipe and clean the entire surface of monitor. Inspect to ensure all areas are clean. 4. Allow product to remain on equipment according to manufacturer's recommendations. 5. Remove and discard gloves. Sanitize hands.The policy Enhanced Barrier Precautions, dated 10/16/23, documents, Staff utilize gown and gloves for high contact resident care activities when residents require EBP (Enhanced Barrier Precautions); high contact activities may include Device Care or use: central line, urinary catheter, feeding tube, tracheostomy / ventilator.The Policy Hand Hygiene, dated 1/24, documents, hand hygiene is done before and after resident contact, before and after any procedure.The Tracheostomy Care Policy, dated 10/24, documents, Procedure: III. Tracheostomy care. B.

Gather equipment and apply sterile gloves; maintain sterility of the dominant hand. It continues, D. Wash hands, open tracheotomy kit, don gloves, and arrange contents on the sterile field.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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