Inspection·June 11, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R8's POS for 5/2025 documents diagnoses of hyperglycemia, type 2 diabetes mellitus without complications. R8's MAR for 5/2025 documents his morning medications as fluoxetine oral tablet 20 mg, give 3 tablets by mouth in the morning for anxiety. 8:00 AM; Olanzapine oral tablet 20 mg, give 20 mg by mouth in the morning for anxiety, 8:00 AM; Omeprazole oral capsule delayed release 20 mg, give 20 mg by mouth 1x day for indigestion, 8:00 AM; Sitagliptin phosphate oral tablet, give 50 mg by mouth one time a day for prophylaxis, 8:00 AM. On 6/7/2025 at 11:19 AM, R8 stated nobody had given him any of his morning medications and it was almost lunch now. 4. R9's MDS dated [DATE] documents he was cognitively intact for decision making of activities of daily living R9's POS for 5/2025 documents diagnoses of hypotension and chest pain. R9's MAR for 5/2025 documents vitamin B12, give 1000 mcg (micrograms) by mouth one time a day for anemia. 8 AM; Ferrous sulfate oral tablet give 325 mg by mouth one time a day for anemia, 8:00 AM; Fludrocortisone acetate oral tablet 0.1 mg (milligram) give 1 tablet by mouth one time a day for low blood pressure, 8:00 AM. On 6/7/2025 at 11: 22 AM, R9 stated the nurse had not yet been on their hall to give anyone their morning medications and some residents really need their medications. 5. R10's MDS dated [DATE] documents he was cognitively intact for decision making of activities of daily living. R10's POS for 5/2025 documents a diagnosis of major depression, type 2 diabetes mellitus without complications, major depression disorder, recurrent, severe with psychotic symptoms, and essential hypertension. R10's MAR for 5/2025 document, Abilify oral tablet 10 mg, give 1 time a day for depression 8 AM. Fluoxetine HCL oral capsule 40 mg give 1 capsule by mouth one time a day for depression, 8 AM. Metoprolol succinate ER oral tablet extended release 24 hours 25 mg, give 1 tablet by mouth one time a day for hypertension, 8 AM. Divalproex sodium ER oral tablet extended release give 1 tablet by mouth two times a day for prophylaxis, 8 AM. Metformin HCL oral tablet 500 mg give 1 tablet by mouth two times a day, 8 AM. On 6/7/2025 at 11:24 AM, R10 stated he had not gotten any medications yet this morning, and he takes seizure medication, and it is important that his medication is not late, but it is now late. On 6/7/2025 at 11:25 AM, there was no nurse on the 400-hall passing out medication and no AM medications had been passed yet for the 400-hall. R6, R8, R9 and R10 reside on the 400-halll. On 6/7/2025 at 11:58 AM, V12, Licensed Practical Nurse (LPN)/Agency stated, I am running late this morning because I had another resident, and they had a change of condition. I am not sure if it was a stroke, but I had to send them out to the hospital. I am behind passing out medication now. I have not had time to notify the physician. I am behind and I still have to do part of the 400-hall and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145290 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nexus Pavilion at Belleville 727 North 17th Street Belleville, IL 62226 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 contact the doctor. I am late with medication today. Level of Harm - Minimal harm or potential for actual harm On 6/7/2025 at 12:09 PM, V8, Regional Nurse stated they would be contacting the physician to let them know medications were passed out late this morning. V8 stated Back in my day the other nurses would pitch in and help out if someone was running late. Normally they would consider an 8 AM medication to be passed out an hour earlier and or hour late but anything after 9 AM, for an 8 AM medication would be considered late. Residents Affected - Some The Medication Administration Policy dated 4/24 documents, GENERAL: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Licensed staff will administer medications as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145290 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nexus Pavilion at Belleville 727 North 17th Street Belleville, IL 62226 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the facility failed to maintain an effective pest control system to eradicate bed bugs. This has the potential to affect all 113 residents living in the facility. Residents Affected - Many Findings include: On 6/6/2025 at 9:00AM R3 stated I did not see the bed bugs. The Certified Nursing Assistants, CNAs, woke me up and they sprayed the room, took the sheets off, and I don't know where I went. They were in my roommate's bed. I am just waiting for all clear to get back to my room. On 6/6/2025 at 12:00PM R4 stated he was out of his room in the night because the staff found bed bugs in his bed. R4 stated the staff bagged his items and he had a sponge bath. He was taken to another room for the night and is still not back in his room. He denied knowing he had bed bugs. On 6/6/2025 at 8:30AM V1, Administrator, stated I got a call last night that the staff had found bed bugs in a resident room. I told them to follow the procedures. They are to put the linens in bags and wash. They are to bag all the residents' belongings. The residents are to be showered. We had a pest control company come and spray. We were just recently cited for bed bugs. On 6/6/2025 at 10:00AM V5, CNA supervisor stated I got called in the middle of the night. The CNAs were doing rounds and found bed bugs. They bagged everything up and showered the residents. The residents were switched to different rooms. On 6/6/2025 at 12:05PM V6, CNA, stated This place is infested with bed bugs. I have seen them in resident's bed before. It's an ongoing problem. On 6/6/2025 at 1:15PM V7, Maintenance Director, stated When I came in this morning, I sprayed every room in the facility, the common areas and down by laundry. We do inspections daily and spray any hotspots. We use bed bug spray, and we have the pest control company come spray too. The facility's invoices for pest control were reviewed. The last invoice provided was dated 4/9/25 with no reference to bed bugs. On 6/6/2025 at 12:45 PM pest control company representative stated the facility has a contract for ongoing general pest control service. Most current specific treatment for bed bugs was dated 12/21/2024. Facility policy with a revision date of 8/2024 states Facility shall maintain an effective pest control program. The facility's resident daily census documents there are 113 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145290 If continuation sheet Page 4 of 4