Nexus at Berwyn

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the rights of 1 of 7 residents (R2) in maintaining the right to have a choice and preference about lighting in the room in the sample reviewed for resident rights. This failure affected R2, who did not want the window blind drawn for lighting in the room and denied the right to do so by staff. This has the potential to affect all 133 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly; failed to ensure that the outside dumpsters were closed; and failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. These failures have the potential to affect all 144 residents residing at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to initiate and continue cardiopulmonary resuscitation (CPR) for one resident (R1) who required resuscitative care until Emergency Medical Services (EMS) assumed resuscitative efforts. This failure has the potential to affect 106 residents that are identified as full code. The Immediate Jeopardy began on [DATE] when facility staff failed to ensure, CPR was conducted after R1 was found to be unresponsive and cold blue called. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 3:45pm. The surveyor confirmed by onsite observation, record review and interview that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner that maintains resident dignity and resident rights. This deficiency affects one (R5) of eight residents reviewed for Resident Rights.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's right to be informed of their health status and participate in treatment decisions, the facility failed to honor a resident's request to be transferred to the hospital for evaluation of shortness of breath for one of one resident (R6) reviewed for resident rights.

Inspectors wroteBased on interview and record review the facility failed to ensure family and hospice services were notified of a condition change for one of two residents (R6) reviewed for Hospice care. Findings Include:On 1/28/2026 at 12:15 noon R6 said that on 1/12/2026 she was short of breath and coughing until her chest hurt and asked V17(Nurse) to send her to the hospital and V17 refused telling her she is in hospice care, she only has a cough and is not short of breath. R6 then had her roommate call 911. On 1/28/2026 at 1:00pm V17 said R6 was very uncooperative with staff and refusing care, she had a small cough and wanted to be transferred to the hospital , I informed her that she did not need to be transferred to the hospital for a cough, then shortly 911 arrived and said they had a 911 call and had to take R6 to the hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's personal privacy for medical records. This deficiency affects two (R9 and R10) of eight residents reviewed for Resident Privacy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a dependent resident received assistance with ADL'S (activity of daily living) related to incontinence care for 1 of 3 residents ( R8) reviewed for ADL's.

Inspectors wroteBased on interview and record review, the facility failed to prevent a cognitively impaired resident (R2) from obtaining severe burns from a radiator heater connected to the wall after R2 rolled out of bed onto the radiator heater when R2's bed was pushed against the wall for one out of three residents reviewed for accidents and incidents in a total sample of seven. This failure resulted in R2 suffering a first degree burn to the right cheek and second and third degree burns to the right arm and right leg requiring an intensive care unit hospitalization on a burn unit for five days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to its residents by not cleaning up the mold in the shower room. This applies to 11 residents (R1-R11) reviewed for a safe, functional, and sanitary environment in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to follow their Indwelling Catheter Care policy by not promoting comfort or cleanliness for one resident (R101) who was diagnosed with Neuromuscular Dysfunction of Bladder. This failure resulted in R101 being sent to the hospital with a fever, a grossly soiled indwelling catheter which was wrapped up in his gluteal (buttock) fold, around his leg with purulence (pus) drainage and tenderness noted to penis and lower abdominal. R101 was admitted with the diagnosis of Urinary Tract Infection associated with indwelling urethral catheter which required antibiotics for one of one reviewed for catheters. Findings Include: R101 was diagnosed with Neuromuscular Dysfunction of Bladder. Brief interview for mental status dated 12/3/25 documents a score of eleven which indicates moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its grievance policy and resolve a grievance within 7 days for one resident (R33) out of three reviewed for grievances in a sample of 58.

Inspectors wroteBased on observation, interview and record the facility failed to follow their fire prevention policy by not ensuring residents where free from hazardous fire conditions. This affected one of three residents (R9) reviewed for resident safety. This failure resulted in R9 having a refrigerator plugged into an unapproved, non-medical grade, surge protector which sparked and ignited a small fire leaving black smoke in the room and soot on the floor. This failure has the potential to affect all the twenty- two resident who reside on the units.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident from physical abuse during resident-to-resident altercation. This deficiency affects one (R1) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to follow the physician ordered to ensure as needed pain medications (Norco, Tramadol, Gabapentin, and Tylenol) were administered to residents as prescribed. This affected two of three (R1, R2) residents reviewed pain management. This failure resulted in R1 suffering a psychosocial harm and stated that R1 endured excruciating pain due to not getting his pain medications. R2 said R2 needed pain medication, rated his pain as 8 on a scale of 1 to 10, but his medication was not available.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff administer ordered pain medications to residents according to resident's needs and as outlined in their care plan and failed to ensure that resident's medications readily available. These failures affected two residents (R1 and R2) of four residents reviewed for pain management and have the potential to affect all 45 residents on the first floor of the facility. This failure resulted in R1 and R2 missed multiple doses of about 9 different pain medications while at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident personal washroom was equipped with toilet tissue/rolls in a timely manner in the resident's bathroom for personal hygiene. This failure affected 4 of 4 residents (R4, R6, R7 and R12) reviewed for personal hygiene equipment toilet rolls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that emergency cart, treatment cart was locked when not in proximity of the nurse and individual medications were locked up safely in the medication cart to prevent tampering and accidental hazard. This failure affected 2 of 2 residents (R3 and R1) in the sample reviewed for medication administration.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement effective individualized fall interventions to prevent fall incidents and fall incidents with injury for residents identified as high risk for falls, with severe cognitive impairment and assessed with poor awareness. This affected two (R2 and R5) of three residents reviewed for incidents/accidents. This failure resulted in R2 having multiple falls with self-transfer attempts and R5 with history of wandering behavior, had a fall and found by the third floor exit door on 4/10/25. R5 transferred to local hospital for evaluation and returned with new diagnosis of closed nondisplaced fracture of proximal end of left humerus. Findings Include: R2 admitted in the facility on 9/16/24 with diagnoses of but not limited to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an available manual resuscitator and failed to provide timely suctioning care for two (R1 and R6) out of three residents with a tracheostomy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices to resident on tracheostomy tube and during medication administration. This deficiency affects all five (R19, R66, R93, R108 and R110) residents in the sample of 25 reviewed for Infection Control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects two (R68, R78) of three residents in the sample for 25 reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail and foot care to dependent resident. The facility also failed to incontinence care to dependent and incontinent resident in a timely manner. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Activity of daily living (ADL) Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement measures to prevent resident from acquiring pressure ulcer in the facility and updated wound care plan intervention. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Wound/Pressure Ulcer Prevention and management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing assessment was in place for a totally dependent resident who has limited range of motion (ROM) to prevent contractures. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Restorative Nursing Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision is rendered to dependent resident who is at high risk and had several unwitnessed falls in his room. This deficiency affects one (R108) of three residents in the sample of 25 reviewed for Fall prevention program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that Medication error rates are not 5 percent or greater. This deficiency affects one (R66) of four residents in a sample of 25 reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to develop a fall care plan with interventions to prevent a fall of a resident (R1) who was assessed as high fall risk. These failures affected one (R1) of three residents reviewed for falls and resulted in R1 sustaining broken ribs, left shoulder out of socket and fluid in muscle as a result of a fall.

Inspectors wroteBased on interviews and record review, the facility failed to follow their Laboratory Specimens policy. Facility failed to send urine specimen labeled and with requisition, resulting in laboratory unable to process Urinalysis and Culture/Sensitivity test. This deficiency practice affects one resident (R1) of three residents reviewed for quality of care. Findings Include: R1 admitted in the facility on 8/10/23. BIMS of 15 (Intact Cognition) On 1/14/25 at 11AM, R1 stated that her urine sample was taken twice in the facility, does not recall exactly when in December. The urine sample was taken the same day R1 reported an odor in her urine. First urine sample, R1 was informed that the urine sample was not labeled. And then the second sample was taken, and R1 was informed by the NP, saying that the urine sample says the lab received it, however no result can be found. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident has the right to receive unopened personal mail in a timely manner. This failure affected one (R3) resident in a sample of 6 residents reviewed for privacy and resident rights.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary transportation for a resident to attend a doctor's appointment outside of the facility for 1 of 3 residents (R1) reviewed for necessary care and services in the sample 5.

Inspectors wroteBased on interview and record review the facility failed to obtain medication from the pharmacy for 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to identify and treat an open wound. This affected one of three residents (R1) reviewed for skin assessment and wound care. This failure resulted in R1 being admitted to the hospital where the open wound was found and treated for maggots present in the wound. Findings Include: R1 is a [AGE] year old with the following diagnosis: end stage renal disease with dependence on renal dialysis, type 2 diabetes, heart failure, and transient ischemic attacks. A General note dated 7/6/24 documents the nurse contacted the physician to inform them about R1's left leg swelling. Orders were put in to send R1 to the hospital for an evaluation to rule up blood clots. R1 was transported to the hospital at 12:06 AM. R1 was admitted to the hospital to a step down unit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain consent for psychotropic medications prior to administering. This failure affected one of one (R2) resident reviewed for unnecessary psychotropic medications and resulted in R2 experiencing increased lethargy and concern from family members.

Inspectors wroteBased on interview and record review, the facility failed to initiate discharge for a resident upon request and failed to update the discharge care plan to include a desire for transfer or discharge which affected one (R2) of two residents reviewed for discharge planning.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for two of two (R2, R3) residents reviewed for medication administration by inaccurately transcribing a medication for R2 and by not ensuring timely ordering of medications for R3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure stock medications, eye drops and insulins were labeled with open and expiration date, failed to label multidose vials and multidose liquid medications and failed to dispose expired medications. These failures affected 8 (R2, R7, R8, R16, R23, R42, R69 and R100,) residents reviewed for medication storage and labeling and have the potential to affect 126 residents receiving medications on all floors. Three out of six medication carts and three out of three medication rooms reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review the facility failed to document medication administration in the Electronic Medical Record in accordance with acceptable clinical practice for seven (R29, R109, R17, R64, R28, R86, R25) residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provide shower/bed bath and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected 6 residents (R3, R7, R21, R47, R78, R99) of 11 residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing coverage to adequately meet the residents care needs. This failure has the potential to affect all 45 residents who are currently residing on the third floor. Findings Include: Per daily census report dated 4/22/24 shows that 45 total residents reside on the third floor. On 4/22/24 at 11:36AM, R3 stated, she is usually changed after lunch but she has not been changed at all today. R3 stated, the last time she was changed was last night (4/21/24). R3 stated, the staff get upset when I use my call light. V22 (CNA) stated, R3 has not been changed today because they are short staffed. V22 stated, they need to have four CNA's but they only have three CNA's. V22 stated, a lot of the resident's on the third floor need two person assistance and assistance with meals. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were nine (9) medication errors out of 29 medication opportunities, resulting in a 31.03% medication error rate. This applies to 6 residents (R1, R15, R19, R22, R37, R92) of 10 residents observed during medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its enhanced barrier precaution policy by failing to place any signage with informational material on one (R47) resident door or making personal protective equipment (PPE) available inside or outside resident's room perform hand hygiene between glove changes during wound care observation, failed to clean blood pressure machine and glucose monitor device after used between patients. and failed to keep linen in a closed hamper with the lids closed. These failures affect six (R15, R19, R22, R29, R38, R47) residents reviewed for infection control practices Findings Include: On 04/23/24 at 09:15 am, surveyor observed V10 (License Practical Nurse) taking blood pressure on R15, then on R22 without cleaning the blood pressure cuff. [...]

Inspectors wroteBased on interview and record review the facility failed to refer a resident with a new mental health diagnosis for a level II PASARR assessment. This failure applies to one of three residents (R102) reviewed for PASARR assessments.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for comprehensive care planning by not developing and implementing person centered care plan interventions for a resident who refused ADL (Activities of Daily Living) care, a resident with a history of substance use who was observed to be under the suspicion of substance use, and a resident with a history of aggressive and maladaptive behaviors. This failure applies to three of three residents (R78, R85, and R102) reviewed for care planning.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedure for ensuring residents are provided necessary behavioral health care and services to maintain their highest practicable mental and psychosocial wellbeing consistent with a comprehensive assessment and plan of care and for the prevention and treatment of substance use disorders by not developing comprehensive person-centered care plans, and not reporting signs of resident substance use to social services,. This failure applies to two of three residents (R85, and R102) reviewed for behaviors.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to safely reposition a resident during direct resident care and failed to ensure supervision of residents with a history of aggression. This affected five of six residents reviewed (R3, R4, R7, R8, & R9) reviewed for supervision and safety. This failure resulted in R9 rolling from the bed while receiving incontinence care sustaining a laceration to the head and treated at the local hospital. The failure also resulted in R4 attacking R3 with a butter knife, and R8 throwing a walker and striking R7. Based on interview and record review the facility failed to follow their elopement policy by not contacting the local police for one resident. This affected one of three residents (R14) reviewed for resident safety. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse prevention policy to prevent incidents of resident-to-resident abuse. This affected six of eight residents reviewed (R3 - R8) reviewed for resident-to-resident abuse. This failure resulted in R4 stabbing R3 with a butter knife after a verbal disagreement, R8 throwing a walker at and hitting R7 causing a bruise, and R6 slapping R5 in the face with a open hand.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its abuse policy and immediately report an incident of resident-to-resident abuse to the regulatory agency. This affected two of six residents (R3, R4) reviewed for abuse policy and reporting. This failure resulted in a delay in reporting for over 2 months.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy for gastric tube medication administration for one resident (R28) of five residents reviewed for medication administration in the sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans for residents with specialized needs for two (R80, R366) of 12 residents reviewed for care plans in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply compression stockings for one (R72) of one resident reviewed for edema in a sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to verify placement of a gastric tube before administering medication to one resident (R28) of five residents reviewed for medication administration in the sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician orders for a CPAP (Continuous Positive Airway Pressure) machine for one resident (R80) of four residents reviewed for respiratory care in the sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of medications after the use by date in two of three medication carts reviewed for medication and storage.