Nexus At Palos
Nexus at Palos in PALOS HILLS, IL — inspection on September 5, 2025.
Found 2 citations. 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.
Inspection Findings
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 (R2) reviewed for incontinence care.
Findings include: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 R2 as required for incontinence.On 9/2/25 at 12:10pm, R2 was observed sitting in his wheelchair, urinating on the floor with his clothes on while attempting to eat his lunch tray. R2's jogging pants were observed with wet pants in between his legs.On 9/2/25 at 12:15pm, V8 (restorative) said, R2's jogging paints were wet in between his leg. V8 said, R2 was soiled and saturated with urine.On 9/2/25 at 1:05pm, V6 (CNA) said, she last provided incontinence care for 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.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Nexus at Palos
10426 South Roberts Palos Hills, IL 60465
SUMMARY STATEMENT OF DEFICIENCIES
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 (R4).
This resulted in R4 sustaining a fall, being transferred to the local hospital with a diagnosis of scalp hematoma.
Findings include:R4 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease, weakness, and difficulty walking. 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. R4'sR4's incident report dated 8/7/25 documents while receiving Activities of daily living (ADL) care patient slid out of bed.R4's functional ability and goals assessment dated [DATE] 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.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 R4. V2 said she was assisting V19 (CNA) with 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 R4 causing her to jerk and start to slide off the bed.
V2 said she was unable to stop 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 R4. V19 said R4 is total care and requires two people for all care. V19 said 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 R4 starting to go forward because she could hold her weight. R4 fell to the ground.On 9/4/25 at 4:30PM, V16 (restorative nurse) said 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. 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. R4's hospital discharge paperwork dated 8/7/25 indicates fall with scalp hematoma.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.