Nexus at Palos

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 3, 2026

  Based on interviews and record review, the facility failed to supervise R1 who was diagnosed with Mild Dementia with moderate cognitive impairment, who was identified as incapable of unsupervised outside pass privileges, scored as high risk for elopement with exit-seeking behavior from leaving the facility unauthorized via an unknown exit/egress door, crossing a busy intersection, getting lost on a pace bus traveling approximately twelve miles to 95th and the [NAME] which is a high-traffic, multi-lane intersection with significant vehicle volume that includes access points to a major expressway (The [NAME] Expressway (I-90/I-94) is a11.47-mile, 8-to-16 lane, heavily traveled artery in Chicago, carrying over 300,000 vehicles daily from downtown to the South Side) for 1 of 3 residents… […]

• Immediate jeopardy, isolatedF695Sep 2, 2025

  Based on interview and record review, the facility failed to implement respiratory care interventions including ensuring the application of hand mitten restraint as ordered, and to maintain patency of trach tubes due to resident history of chronic pulling of tracheostomy tube according to the plan of care for 1 of 3 (R4) residents reviewed for tracheostomy care. As a result of the facility's noncompliance with mittens not being applied and monitored by staff, R4 was able to reach her tracheostomy tubing and self-decannulated which led to her expiring. […]

• Actual harm, isolatedF580May 29, 2026

  Based on interview and record review, the facility failed to follow its policy regarding notification of changes in resident condition by failing to notify the physician and/or nurse practitioner of a resident's new complaint of pain and inability to bear weight on the right lower extremity. This affected one of three residents reviewed for change in condition notification. The failure resulted in a delay in assessment and treatment of an undiagnosed right hip fracture. This failure affected one (R3) of three residents reviewed for notification.Findings include:R3 was admitted to the facility on [DATE] with diagnoses of history of malignant neoplasm of breast, weakness, mixed hyperlipidemia, unspecified fall, hypotension, anxiety disorder, insomnia, unspecified severe protein calorie… […]

• Actual harm, isolatedF684May 29, 2026

  Based on interview and record review, the facility failed to provide appropriate nursing care and follow physician recommendations by failing to obtain a right hip x-ray after a Resident experienced a fall and subsequently exhibited redness to the right hip. This deficient practice affected one of three residents reviewed for improper nursing care. This failure resulted in a delay in diagnostic evaluation, assessment and treatment of a injury. Following a change in condition, R3 was transferred to the hospital, where diagnostic imaging revealed a right hip fracture.Findings include:Based on interview and record review, the facility failed to provide appropriate nursing care and follow physician recommendations by failing to obtain a right hip x-ray after a resident experienced a fall and… […]

• Actual harm, isolatedF697May 29, 2026

  Based on interview and record review, the facility failed to follow its pain management policy by failing to adequately assess, monitor, and manage pain for one of three (R3) reviewed for pain management. This failure resulted in R3 following a fall, experiencing ongoing right lower extremity pain that was not comprehensively evaluated or effectively managed. This resulted in R3 experiencing unmanaged pain, an inability to fully participate in therapy services.Findings include:R3 was admitted to the facility on [DATE] with diagnoses of history of malignant neoplasm of breast, weakness, mixed hyperlipidemia, unspecified fall, hypotension, anxiety disorder, insomnia, unspecified severe protein calorie malnutrition, major depressive disorder, constipation, alcohol abuse, gastroesophageal… […]