Inspection·July 23, 2025

F 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete get his morning pain pill but stated they never ask him what his pain level is, they just hand him his pills. R3 stated right now, his pain is an 8 and it typically is between 6 to 8 depending on if he is lying down or up moving around.On 7/23/25 at 9:30 AM, V2 stated I would expect the nurses to provide pain medications as ordered to maintain the resident's level of pain to a minimum and if they run out of the medication, I would expect the nurses to order the medications when they run out in a timely manner, so the resident does not go without getting them. I would expect the nurses to administer antibiotics as ordered for any resident.R3's Physician Order (PO), dated 6/28/25, documents Oxycodone HCl (Hydrochloride) Oral Tablet 5 MG (milligram), give 1 tablet by mouth every 6 hours as needed for pain take 1-2-tab 5-10 MG by mouth every 6 hours as needed. Max daily amount 40 MG. This order was discontinued on 7/1/25. R3's PO, dated 7/1/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours as needed for pain take 1 tab (5 MG) for pain scale 1-4 and 2 tabs (10 MG) for pain scale 5-10 by mouth every 6 hours as needed. Max daily amount 40 MG. This order was discontinued on 7/16/25.R3's PO, dated 7/16/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours as needed for pain. This order was discontinued on 7/18/25. R3's PO, dated 7/18/25, documents Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 6 hours related to Methicillin Resistant Staphylococcus Aureus Infection.V2 provided the Controlled Substance Receipt/Record/Disposition Form for R3's Oxycodone, dated 6/29/25. This form documents R3 did receive Oxycodone from 6/29/25 up to 7/6/25 with nothing documented past 7/6/25. V2 stated this is what they have for documentation of R3 getting his Oxycodone.R3's Electronic Health Record (EHR), Weights/Vitals, Pain Level, documents R3 was experiencing pain on 7/7/25 at a 6 with no Oxycodone given, on 7/8/25 at 00:21 AM at a 5 with no Oxycodone given, on 7/8/25 at 6:19 AM at a 3 with no Oxycodone given, on 7/8/25 at 9:08 AM at a 5 with no Oxycodone given, on 7/8/25 at 9:09 AM at a 5 with no Oxycodone given, and on 7/9/25 at 7:36 AM at a 3 with no Oxycodone given. R3's Medication Administration Record (MAR), dated July 2025, documents R3's Pain Level on 7/7/25 during evening was a 5, on 7/8/25 during days was a 5, on 7/9/25 during days was a 3 and during evenings was also a 3. There was no Oxycodone given to R3 during the time frame from 7/5/25 at 5:30 PM through 7/12/25 at 7:58 AM. The Facility's Pain Management Policy, dated 10/2024, documents General: To facilitate and provide guidance on pain observations and management. To facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, providing our resident's the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. Guideline: The pain management program is based on a facility-wide commitment to resident comfort. pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Policy: 1. Pain is assessed using the Comprehensive Pain Assessment form: Upon admission, quarterly, with significant change, following a fall, when new pain is identified, when existing pain worsens. 2. Pain will be assessed at least once every shift and documented in the EMAR using the pain scale appropriate for the patient.3. Development of the Care Plan. 4. If nursing recognizes pain, the staff may attempt non-pharmacological interventions, physical modalities, body alignment, rehabilitation therapy, exercises, and/or cognitive/behavioral interventions. 5. 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. Event ID: Facility ID: 145290 If continuation sheet Page 2 of 5 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 07/23/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, and record review, the facility failed to provide an antibiotic for 1 of 1 resident (R3) reviewed for medication administration in the sample of 6. This failure resulted in R3 not receiving his antibiotic as ordered, his Vancomycin Trough levels subtherapeutic therefore not sufficient in treating R3's Methicillin Resistant Staphylococcus Aureus (MRSA) infection in his lungs. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus Type 2 (DM2), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing), report any acute changes to Physician. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact, is independent on all ADLs. R3 is always continent of both bowel and bladder. On 7/21/25 at 1:25 PM, R3 stated I have a PICC (Peripherally Inserted Central Catheter) line in my right arm and I am supposed to get antibiotics in it twice a day. I have not received my antibiotic yet today that I was supposed to get this am. I think the IV pump is broke and that is why I am not receiving it.On 7/21/25 at 1:37 PM, V7, Registered Nurse/Nurse Practitioner (NP), stated I did not give (R3) his antibiotic this morning because he had a trough drawn and I have to wait until that result comes back in order to give this dose, in case I have to hold the dose.On 7/22/25 at 9:00 AM, R3 stated That bag is still hanging from yesterday because the nurse could not give it to me because the pump was broke. A bag of Vancomycin 1750 MG (milligram)/500 ML (milliliter) was seen hanging and attached to the IV pump which was turned off. On 7/22/25 at 9:15 AM, V7 stated The bag of antibiotics hanging in (R3's) room is the one from yesterday. I got the trough level back yesterday and went to hang it and the IV pump would not work. I even had another nurse try and the same thing. I called the pharmacy this morning and spoke with them, and they stated they would bring us a new pump today. The pharmacy showed up this morning and only delivered bags of antibiotics and no pump, so we still can't give (R3) his antibiotic. I told the DON of the situation.On 7/23/25 at 8:55 AM, V10, NP, stated I was not notified that (R3) was not receiving his antibiotic. I would expect the nurses to give the antibiotics as ordered. There is definitely a potential that (R3's) condition could get worse, or not get any better, by not getting his antibiotic. I also was not notified that (R3) was not receiving his Oxycodone for pain. I did meet with (R3) and the DON about (R3's) pain and I was not sure if it was lung pain or muscular pain and the way the Oxycodone was ordered, I wasn't sure if he was getting 5 MG or 10 MG, so I just made it 5 MG every 6 hours and added the Cyclobenzaprine to help with his muscles. I would expect the nurses to give (R3) his pain medication to keep up with his pain control. Any foreign substance in our lungs causes pain and with (R3) having a lesion with MRSA in his lung, it definitely has the potential to be painful, especially if it is not getting any better.On 7/23/25 at 9:30 AM, V2 stated I would expect the nurses to order the medications when they run out in a timely manner, so the resident does not go without getting them. I would also expect the nurses to administer antibiotics as ordered for any resident.R3's Physician Order (PO), dated 6/28/25, documents Micafungin Sodium Intravenous Solution Reconstituted 100 MG, use 100 MG intravenously (IV) one time a day for Antifungal for 12 Days inject 1 dose by IV every 24hrs. This was discontinued on 7/8/25.R3's PO, dated 7/8/25, documents Micafungin Sodium Intravenous Solution Reconstituted 100 MG, use 100 mg intravenously one time a day for Antifungal for 12 Days inject 1 dose by IV every Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145290 If continuation sheet Page 3 of 5 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 07/23/2025 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 0760 Level of Harm - Actual harm Residents Affected - Few 24hrs.R3's PO, dated 6/28/25, documents Vancomycin HCl Intravenous Solution 1500 MG/300ML, use 1 dose intravenously every 12 hours for Anti- infection for 41 Days. This was discontinued on 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1750 MG/350ML, use 1 dose intravenously every 12 hours related to Methicillin Resistant Staphylococcus Aureus Infection. This was discontinued 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1500 MG/300ML, use 1 dose intravenously every 12 hours for Anti- infection until 07/18/2025 23:59. This was discontinued 7/18/25.R3's PO, dated 7/18/25, documents Vancomycin HCl Intravenous Solution 1750 MG/350ML, use 1 dose intravenously every 12 hours related to Methicillin Resistant Staphylococcus Aureus Infection. This is the current order. R3's Medication Administration Record (MAR), dated July 2025, does not show that R3 received Vancomycin IV as ordered on 7/6/25 AM dose, 7/9/25 AM dose, 7/13/25 AM dose, 7/20/25 AM dose, and 7/21/25 both AM and PM doses. R3's MAR, dated July 2025, does not show that R3 received Micafungin IV as ordered on 7/7/25, 7/8/25, 7/15/25, and on 7/20/25. R3's Nursing Note, dated 7/21/25 at 3:56 PM, documents Resident missed AM dose of IV Vancomycin yesterday. NP notified. No signs/symptoms of infection noted.R3's Nurses Note, dated 7/21/25 at 4:11 PM, documents Nurse informed (facility pharmacy) about the malfunction of the IV pump. The IV pump will be sent out today along with the medication run. Dr. (doctor) ordered that the PICC line dressing be changed weekly.R3's Nurses Note, dated 7/22/25 at 8:28 AM, documents the nurse contacted (facility pharmacy) to discuss the delivery issue with the IV pump. (Pharmacy) explained that the courier had left the pump, and another pump would be delivered promptly. The courier and DON were notified about the missing dose of medication. The corporate nurse delivered the pump from an affiliate facility. The IV medication was administered to the patient without any difficulties. The PICC line was flushed and found to be patent, with no signs of redness or warmth at the site. Monitoring will continue.R3's Nurses Note, dated 7/22/25 at 3:24 PM, documents NP on call notified of missed Vancomycin doses and verbal order received to extend medication x 2 doses. Resident is afebrile, no s/s (signs/symptoms) of infection noted at this time.R3's Acute Care (NP) Note, dated 7/23/25 at 00:35 AM, documents in part Nurse reports pt (patient) missed 2 doses of Vancomycin. (R3) is a [AGE] year-old male with PMH (primary medical history) of DM2, and acute on chronic pancreatitis. He was admitted to the hospital on [DATE]rd after previously leaving AMA (against medical advice). He was found to have MRSA bacteremia with a right upper lobe abscess versus infarct and perirenal abscess. Bronchoscopy on June 18th showed MRSA, Group B-Strep, and Serratia. He received a PICC line, and he was on vancomycin and Ceftazidime, with Fluconazole added due to thrush. He was admitted to (this facility) on 6/28 for LTC (long term care) and continuation of IV abx (antibiotics).R3's Lab Result, Vancomycin Trough Level, dated 7/11/25, documents R3's Vancomycin level was 8.5 (Low) with a reference range of 10.0 to 20.0. R3's Lab Result, Vancomycin Trough Level, dated 7/17/25, documents R3's Vancomycin level was 9.0 (Low) with a reference range of 10.0 to 20.0. R3's Lab Result, Vancomycin Trough Level, dated 7/21/25, documents R3's Vancomycin level was 8.6 (Low) with a reference range of 10.0 to 20.0. The Facility's Medication Administration Policy, dated 4/2024, documents in part 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. Guideline: 22. If a medication is not given as ordered, document the reason on the MAR and notify the Health Care Provider if required. 26. If medication is ordered, but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain it from the contingency or convenience box. 27. If the physician's order cannot be followed for any reason, the physician should be notified in a timely manner (depending on the situation), and a note should reflect the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145290 If continuation sheet Page 4 of 5 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 07/23/2025 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 0760 situation in the resident's medical record. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145290 If continuation sheet Page 5 of 5