Nexus at Alton

In the surveyor’s words

From the most serious findings on record at Nexus at Alton, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 14, 2026

  Based on interview, observation, and record review the facility failed to supervise a high-risk, exit seeking resident to prevent an elopement in 1 of 4 residents (R2) reviewed for supervision in the sample of 9. This failure resulted in R2 having multiple elopement attempts from 7/27/26 until he eloped on 8/10/26 at approximately 8:30 PM, R2 traveled approximately 3 miles along a busy 4 lane highway. R2 was found by police at approximately 10:23 PM sitting on his buttocks on the ground in the drive thru at a fast-food restaurant. This failure resulted in an Immediate Jeopardy. V1, Administrator, and V15, Regional Nurse Consultant were notified of the Immediate Jeopardy on 8/13/26 at 3:00 PM. […]

• Immediate jeopardy, isolatedF689Nov 14, 2023

  Based on interview, observation and record review, the facility failed to adequately supervise a resident to prevent an elopement of 1 of 3 residents (R2) reviewed for supervision. This failure resulted in R2 eloping from the facility. R2 was gone from the facility for approximately 14 hours and sustained a fractured right tibia while out of the facility. On 11/07/23 at 2:50pm V1 Administrator and V2 Don was in room when V1 signed IJ Template. The Immediate Jeopardy began on 10/10/23 approximately 11:00 PM-12:00AM, When R2 eloped from the facility, and was found out in the rain under a tree with a broken leg. The staff was unaware of R2 had exited the facility. Findings include: On 11/3/23 at 2:35 PM, R2 was observed in his room with the privacy curtain pulled all the way around him. […]

• Actual harm, isolatedF550Aug 14, 2026

  Based on observation, interview, and record review, the facility failed to keep a resident's private areas from being exposed for others to see in 1 of 3 residents (R5), when reviewed for resident rights in the sample of 9. Using a reasonable person approach, this failure, verified through interviews regarding R5, who is confused, would cause humiliation, and shame. Findings Include:On 8/12/26 at 7:25 AM, R5 was observed in her room on her mattress on the floor with her gown off, completely exposed with the door open, R5's catheter was on the floor, and she was yelling out help me. R5 is alert to self only. […]

• Actual harm, isolatedF550Jun 21, 2026

  Based on interview, observation and record review the facility failed to treat residents with dignity and respect for 3 of 4 residents; (R6, R7 and R8); reviewed for Resident Rights in a sample of 14. This failure caused R6 to have feelings of being unworthy of care and shamed and feeling worse about herself. This failure caused R7 to feel worse about himself and like he is a bother to staff. This failure caused R8 to feel insignificant.Findings include:1.R6's Facesheet with a print date of 6/18/26 documented she was admitted to the facility on [DATE] with diagnoses of, in part, rheumatoid arthritis, major depressive disorder, chronic pain and anxiety disorder.R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact and requires substantial/maximal assistance with… […]

• Actual harm, isolatedF697Jun 21, 2026

  Based on interview and record review the facility failed to provide pain management for 1 of 5 (R5) residents reviewed for medication administration in a sample of 15. This failure resulted in R5 experiencing excruciating and unbearable pain.Findings include:R5's Care Plan, dated 10/09/2023, documents PAIN: Resident has potential for an alteration in comfort r/t (related to) osteomyelitis and spina bifida.R5's, Minimum Data Set, dated [DATE], documents that R5 was cognitively intact and experiences pain almost daily. R5's Physician Order Sheet documents 4/8/2026 Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours for Pain. […]