F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, that facility failed to provide incontinence care for a resident who was
identified as dependent on staff for toileting for over four hours. This affected one of three residents (R2)
reviewed for incontinence care. Findings include:R2's minimal data set (MDS) section GG (functional
abilities) dated 6/7/25 documents: toilet hygiene dependent. Section H (bladder and bowel) documents:
always incontinent with urinary and bowel continence. Care plan dated 5/16/25 documents: Check R2 as
required for incontinence.On 9/2/25 at 12:10pm, R2 was observed sitting in his wheelchair, urinating on the
floor with his clothes on while attempting to eat his lunch tray. R2's jogging pants were observed with wet
pants in between his legs.On 9/2/25 at 12:15pm, V8 (restorative) said, R2's jogging paints were wet in
between his leg. V8 said, R2 was soiled and saturated with urine.On 9/2/25 at 1:05pm, V6 (CNA) said, she
last provided incontinence care for R2 at 8am.On 9/2/25 at 3:04pm, V6 (CNA) said, resident are supposed
to be changed every two hours.Incontinence Care dated 5/2015 documents: Incontinence care is provided
to keep resident as dry, comfortable an odor free as possible.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145650
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
145650
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Nexus at Palos
10426 South Roberts
Palos Hills, IL 60465
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 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
Note: The nursing home is
disputing this citation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure two staff member were at bedside during
incontinence care for one resident who was high risk for falls and required two person assistance with
turning and repositioning. This affected one of three residents (R4). This resulted in R4 sustaining a fall,
being transferred to the local hospital with a diagnosis of scalp hematoma. Findings include:R4 was
admitted to the facility on [DATE] with a diagnosis of end stage renal disease, weakness, and difficulty
walking. R4 fall risk evaluation dated 7/29/25 documents a score of 10. Facility fall prevention policy dated
8/2024 documents a score of 10 or greater indicates resident is at high risk for falls. R4'sR4's incident
report dated 8/7/25 documents while receiving Activities of daily living (ADL) care patient slid out of
bed.R4's functional ability and goals assessment dated [DATE] documents under toileting: Hygiene and roll
left to right substantial/maximal assistance which indicates helper does more than half the effort. Helper lifts
or holds trunk or limbs and provides more than half the effort.R4's task list date 7/30/25 documents turn
and reposition resident two person assist at all times.On 9/4/25 4:49pm V2 (DON) said she was present
during the fall for R4. V2 said she was assisting V19 (CNA) with R4's care. V2 was on one side of the bed
and V19 (CNA) was on the other side of the bed. V2 said she stepped away from the resident to move or
get the garbage can at the same time V19 (CNA) wiped R4 causing her to jerk and start to slide off the bed.
V2 said she was unable to stop R4 from falling. On 9/5/25 at 3:43PM, V19 (CNA, Certified nursing
assistant) said she was assisting V2 (DON) with incontinence care for R4. V19 said R4 is total care and
requires two people for all care. V19 said R4 was on her side and was cleaning her buttocks. V2 (DON) was
on the other side and went to get the garbage can by the door when R4 starting to go forward because she
could hold her weight. R4 fell to the ground.On 9/4/25 at 4:30PM, V16 (restorative nurse) said R4 requires
two staff members be present during care for safety. V16 said staff should never leave the bedside when
providing care and all items should be at bedside prior. V16 said staff should have never left the resident
bedside during care. V16 said she provided reeducation to staff about ensuring all items are at bedside
prior to starting care. R4's progress note dated 8/7/25 documents: While receiving ADL care patient slid to
floor, head to toe and ROM assessed without deformities or complaints of pain, patient positioned back to
bed with 2 person assist using a mechanical lift, lump to left frontal lobe noted, pain medication
administered by mouth for pain, ice pack applied to head. Doctor and nurse notified, new order: send to
hospital for evaluation and treat. R4's hospital discharge paperwork dated 8/7/25 indicates fall with scalp
hematoma.
Event ID:
Facility ID:
145650
If continuation sheet
Page 2 of 2
