Nexus At Palos

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, that facility failed to provide incontinence care for a resident who was identified as dependent on staff for toileting for over four hours. This affected one of three residents (Resident R2) reviewed for incontinence care. Findings include:Resident R2's minimal data set (MDS) section GG (functional abilities) dated 6/7/25 documents: toilet hygiene dependent. Section H (bladder and bowel) documents: always incontinent with urinary and bowel continence. Care plan dated 5/16/25 documents: Check Resident R2 as required for incontinence.On 9/2/25 at 12:10pm, Resident R2 was observed sitting in his wheelchair, urinating on the floor with his clothes on while attempting to eat his lunch tray. Resident R2's jogging pants were observed with wet pants in between his legs.On 9/2/25 at 12:15pm, V8 (restorative) said, Resident R2's jogging paints were wet in between his leg. V8 said, Resident R2 was soiled and saturated with urine.On 9/2/25 at 1:05pm, V6 (CNA) said, she last provided incontinence care for Resident R2 at 8am.On 9/2/25 at 3:04pm, V6 (CNA) said, resident are supposed to be changed every two hours.Incontinence Care dated 5/2015 documents: Incontinence care is provided to keep resident as dry, comfortable an odor free as possible.

Residents Affected - Few

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

09/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Palos

10426 South Roberts Palos Hills, IL 60465

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 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

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 ensure two staff member were at bedside during incontinence care for one resident who was high risk for falls and required two person assistance with turning and repositioning. This affected one of three residents (Resident R4). This resulted in Resident R4 sustaining a fall, being transferred to the local hospital with a diagnosis of scalp hematoma. Findings include:Resident R4 was admitted to the facility on [DATE REDACTED] with a diagnosis of end stage renal disease, weakness, and difficulty walking. Resident R4 fall risk evaluation dated 7/29/25 documents a score of 10. Facility fall prevention policy dated 8/2024 documents a score of 10 or greater indicates resident is at high risk for falls. Resident R4'sR4's incident report dated 8/7/25 documents while receiving Activities of daily living (ADL) care patient slid out of bed.Resident R4's functional ability and goals assessment dated [DATE REDACTED] documents under toileting: Hygiene and roll left to right substantial/maximal assistance which indicates helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.Resident R4's task list date 7/30/25 documents turn and reposition resident two person assist at all times.On 9/4/25 4:49pm V2 (DON) said she was present

during the fall for Resident R4. V2 said she was assisting V19 (CNA) with Resident R4's care. V2 was on one side of the bed and V19 (CNA) was on the other side of the bed. V2 said she stepped away from the resident to move or get the garbage can at the same time V19 (CNA) wiped Resident R4 causing her to jerk and start to slide off the bed.

V2 said she was unable to stop Resident R4 from falling. On 9/5/25 at 3:43PM, V19 (CNA, Certified nursing assistant) said she was assisting V2 (DON) with incontinence care for Resident R4. V19 said Resident R4 is total care and requires two people for all care. V19 said Resident R4 was on her side and was cleaning her buttocks. V2 (DON) was

on the other side and went to get the garbage can by the door when Resident R4 starting to go forward because she could hold her weight. Resident R4 fell to the ground.On 9/4/25 at 4:30PM, V16 (restorative nurse) said Resident R4 requires two staff members be present during care for safety. V16 said staff should never leave the bedside when providing care and all items should be at bedside prior. V16 said staff should have never left the resident bedside during care. V16 said she provided reeducation to staff about ensuring all items are at bedside prior to starting care. Resident R4's progress note dated 8/7/25 documents: While receiving ADL care patient slid to floor, head to toe and ROM assessed without deformities or complaints of pain, patient positioned back to bed with 2 person assist using a mechanical lift, lump to left frontal lobe noted, pain medication administered by mouth for pain, ice pack applied to head. Doctor and nurse notified, new order: send to hospital for evaluation and treat. Resident R4's hospital discharge paperwork dated 8/7/25 indicates fall with scalp hematoma.

Event ID:

Facility ID:

If continuation sheet