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Complaint Investigation

Nexus At Alton

November 19, 2025 · Alton, IL · 3523 Wickenhauser
Citations 1
CMS Rating 1/5
Beds 181
Provider ID 145427
Healthcare Facility
Nexus At Alton
Alton, IL  ·  View full profile →
Inspection Summary

Nexus at Alton in ALTON, IL — inspection on November 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0755
Pharmacy Service Deficiencies
Actual Harm

not have followed through on that.R1's incident report, dated 11/15/25 at 6:15 AM and authored by V13, documented this writer was notified by the floor nurse that resident's Lyrica is out of stock.

Resident assessed for pain. No c/o pain or discomfort voiced.

Physician notified.

New order obtained to place the medication on hold until the medication becomes available from the pharmacy. R1's progress notes do not document anything regarding this incident report. On 11/19/25 at 10:16 AM V11 Nurse Practitioner stated she checked the physician notification records for R1 and there is nothing documented regarding R1's physician and/or clinician who was on call being notified of R1 being out of Lyrica nor was an order implemented to hold R1's Lyrica until it was delivered to the facility.2.) R3's admission Record, print date of 11/17/25, documented R3 has diagnoses including cerebral infarction, type 2 diabetes mellitus, COPD, hypokalemia, anemia, coagulation defect, hypothyroidism, hyperlipidemia, anxiety disorder, obstructive sleep apnea, hypertension, nonrheumatic mitral valve insufficiency, generalized osteoarthritis, and depression. R3's MDS, dated [DATE], documented R3 is cognitively intact and is dependent on staff and a mechanical lift for transfers to and from her wheelchair. R3's care plan, undated, documented R3 is diabetic, resident is at risk for hypo/hyperglycemia related to diagnosis of diabetes mellitus with interventions including administer medication as ordered. On 11/17/25 at 11:35 AM R3 stated she has not been receiving her Ozempic injection every week as ordered, and the nurses tell her they can't find it when she asks them about it. R3's physician order, print date of 11/19/25 and order date of 10/16/25, for Ozempic documented order summary: Ozempic (2 MG/dose) subcutaneous solution pen-injector 8 MG/3ML (semaglutide), inject 2 mg subcutaneously one time a day every Thursday for diabetes give 2 mg dose, pen should last 28 days - 4 doses. R3's MAR, dated 11/2025, documented Ozempic (2 MG/dose) subcutaneous solution pen-injector 8 MG/3ML (semaglutide).

Inject 2 mg subcutaneously one time a day every Thursday for diabetes, give 2 mg dose, pen should last 28 days, 4 doses.

Administration date of 11/6/25 at 6 PM documented #9 (other/see nurse's note).R3's progress note, dated 11/6/25 at 5:35 PM documented Ozempic (2 MG/dose), inject 2 mg subcutaneously every Thursday for diabetes give 2 mg dose pen should last 28 days, 4 doses, medication not in. On 11/19/25 at 11:06 AM V1 Administrator stated she expects residents to receive their medications as ordered.The facility's Pharmacy Services policy, dated 9/2017, documented pharmacy services are provided by a licensed pharmacy.

The role of the pharmacy, as well as pharmacy policies are outlined in the pharmacy policy manual.

Responsible Party: DON, Administrator.

Guideline: 1.

Pharmaceutical services are available to ensure that resident's medications and biologicals are provided as ordered. 2.

The facility does not accept money, goods, or services free or below cost from any pharmacy. 3.

Pharmaceutical services provide appropriate methods and procedures for the procurement, dispensing and administration of drugs and biologicals per the individual pharmacy policy. 4.

Pharmacy services are monitored to assure that the drug distribution system, to include the ordering, labeling and administering of drugs and biologicals, in is compliance with established policies and procedures. 5.

Pharmacy services are provided on a 24-hour basis.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ALTON, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Nexus at Alton or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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