Nexus Pavilion at Belleville

In the surveyor’s words

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

• Immediate jeopardy, widespreadF600Jan 22, 2025

  Based on interview and record review the facility failed to ensure 1 of 4 residents (R2) was protected from another resident with known sexually inappropriate behaviors resulting in the sexual abuse of R2. This failure has the potential to affect all 123 residents residing at the facility. The Immediate Jeopardy began on 01/07/25 at 2:12 PM, when R3 was admitted back into the facility and the facility failed to initiation a plan of care and interventions to address how residents would be kept safe and free from sexual abuse, resulting in R2 being sexually abused by R3. V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator were notified of the Immediate Jeopardy on 01/17/25 at 09:36 AM. […]

• Immediate jeopardy, widespreadF600Jan 31, 2023

  Based on interview, observation, and record review, the Facility failed to supervise and implement progressive interventions to prevent resident to resident physical abuse. This failure has the potential to affect all 142 residents living in the facility. The Immediate Jeopardy began on 4/25/22 when R2 became physically aggressive throwing objects which hit R8. This same day, he threatened to kill R9. Subsequently, R2 continued to have impulsive aggressive behaviors and physical abused R1, R6 and R11. Due to the facility's failure to address R2's ongoing impulsive aggressive behaviors and provide supervision to prevent these aggressive behaviors, this has the potential to affect all residents in the facility. […]

• Immediate jeopardy, patternF689Mar 15, 2023

  Based on observation, interview, and record review the Facility failed to provide supervision to prevent elopement for 1 of 41 residents (R88) reviewed for elopement in the sample of 75. This failure resulted in R88 eloping from facility and the facility not being aware of when R88 left. R88 was found by the local police department on 1/18/2023 at 11:23 PM and taken to the hospital where he was diagnosed with chronic schizophrenia, noncompliance, and elevated blood pressure. The failure to provide supervision and monitoring and implement care plan interventions to prevent R88 from eloping resulted in an Immediate Jeopardy to the health and safety of R88. […]

• Immediate jeopardy, patternF689Aug 10, 2022

  Based on observation, interview and record review the Facility failed to supervise/monitor and prevent elopement for 1 of 3 residents (R2) reviewed for elopement in the sample of 42. This failure resulted in R2 eloping the facility, being found by local police on 7/27/22 and being hospitalized for seven days. The failure to provide supervision and monitoring and implement care plan interventions to prevent R2 from eloping resulted in an Immediate Jeopardy to the health and safety of R2. Without having access to supervision, medical and psychiatric monitoring, R2 has a likelihood for mental health complications resulting in psychiatric hospitalization s, decline in overall health and possible harm. […]

• Immediate jeopardy, isolatedF689Aug 4, 2025

  Based on interview, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 (R7) of 3 reviewed for elopement in the sample of 13. This failure resulted in R7, a resident with known desire and attempts to leave the facility, eloping from the facility and found 12 miles away approximately 8 hours later by police.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 7/25/25 when the R7 eloped from the facility. V1, Administrator, V2, Director of Nursing (DON), V3, Regional Nurse Consultant (RNC), and V19, Regional Director of Clinical and Operations, were notified of the Immediate Jeopardy on 7/30/25 at 4:08 PM. […]