Nexus At Palos
Nexus at Palos in PALOS HILLS, IL — inspection on May 29, 2026.
Found 3 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
level of 5 out of 10 to RLE (right lower extremity) described as aching, limiting lower body ADL's
and remaining still.
What exacerbates pain is sitting, standing, and bending.R3's progress noted dated
noted.
Family to see resident with concerns and requesting resident to be sent to hospital.
Nurse practitioner and Assistant Director of Nursing made aware.
Progress note dated 12/22/2025 at 2:55 PM (14:55) shows local ambulance arrived at 2:40pm .
All necessary documents are given in hand.
Resident left the facility via stretcher, stable with no signs and symptoms of apparent distress. dressed appropriately for the weather. accompanied by two men crew. escorted to local hospital.R3's progress notes do not document any notification to the doctor or nurse practitioner about pain or changes to right lower extremity.R3's hospital record dated 12/22/26 documents: R3 coming to the hospital for confusion and generalized weakness. R3 complaining of right hip pain.
Under musculoskeletal it documents there is tenderness to palpation of the right hip and tenderness with any range of motion of the right hip.
Right hip x-ray dated 12/22/25 documents: superolateral displaced right femoral neck fracture.
Under HPI: R3 states she may have fallen two weeks ago, Daughter was called who states the last time she saw R3 walking was four weeks ago.
Right femoral neck fracture may have been due to a fall 2 weeks prior to presentation and was contributed to by osteoporosis.On 5/27/26 at 1:06PM, V11 (APRN) said he saw R3 during her stay at the facility. V11 said staff will usually verbally report to him any changes to the residents. V11 said he does not recall ever being notified of any pain in R3's right leg or inability to ambulate. V11 said if he was notified of the pain or changes to her leg, he would have done a thorough assessment of R3's leg and probably would have ordered an x-ray.On 5/27/26 at 3:09PM, V16 (NP) said she was not notified of R3 having any pain or inability to bear weight on right leg. V16 said if she was notified, they would have ordered an x-ray.On 5/27/26 at 10:45AM, V2 (Director of nursing, DON) said if a resident has complaints of pain the doctor or nurse practitioner should be notified of the pain. If resident experiences pain during therapy, its expected the therapist should notify the nurse.
Nurses should then report to the doctor and document any interventions provided. V2 does not recall any concerns related to R3 pain or changes in condition.Facility policy change in resident condition review 9/2025 documents it is the policy of the facility, except in a medical emergency, to alert the resident, resident's physician and resident's responsible party of a change in condition.
Nursing will notify the resident's physician or nurse practitioner when there is a significant change in the resident's physical, mental, or emotional status.
Communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents.Facility policy pain management review date 10/2025 documents: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity.
Licensed nursing may notify the health care provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors.
145650 05/29/2026
Nexus at Palos 10426 South Roberts Palos Hills, IL 60465
dated 12/22/25 documents: superolateral displaced right femoral neck fracture.
Under HPI: R3 states
walking was four weeks ago.
Right femoral neck fracture may have been due to a fall 2 weeks prior to
DON) said she expects all staff to follow physician orders. V2 said all staff are responsible for reviewing progress notes and orders. V2 said the team will review the resident's record following a fall as part of the fall review. V2 said when R3 returned from the hospital she reviewed the chart and saw the progress note on 11/26/25 with hip XRAY order. V2 said she did speak to V3 (nurse), and the nurse was terminated due to the not ordering the x-ray.On 5/27/26 at 3:09PM, V16(NP) said she expects staff nurses to follow any physician recommendations for their residents if they are not available and report to them the following day any changes or orders received by on call physician or tele health.Employee report dated 12/30/25 showed that V3 failed to carry out provider order given on 11/26/2025 approximately 1:38 AM via tele health visit. R3 had fallen. V3 was given orders to obtain X-ray to right hip. V3 did not order nor obtain x-ray for R3. V3 also charted no new orders given.Facility policy Physician orders reviewed 9/2024 documents: Physician orders may be written by the provider or received by telephone by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so.
Verbal orders are those given to the nurse by the physician in person or by telephone, however, they are not written by the physician in the medical record.
Policy Explanation and Compliance Guidelines: Physician orders are followed as written; if there is a question about the order, contact the physician for clarification.
For verbal orders, repeat any prescribed orders back to the physician or health care provider.
Use clarification questions to avoid misunderstandings.
Enter the order into the medical record manually or electronically; complete the order and indicate the name of the physician or health care provider giving the order.
The nurse transcribes the order.
The physician should sign the order on his/her next visit to the facility or within the time frame required by the facility.
Follow through with orders by making appropriate contact or notification (e.g., lab or pharmacy).
145650 05/29/2026
Nexus at Palos 10426 South Roberts Palos Hills, IL 60465
ability or willingness to verbalize pain.
For example, some cultures value stoicism and a high
interventions. It also documents that pain is assessed using the comprehensive pain assessment form
health care provider of any new development of pain, change in pain, change in condition that could potentially cause pain, for pharmacological interventions based on the individual's pain factors.
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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.