Federal inspectors visiting Nexus at Berwyn in December found blackish mold covering the bottom of all four walls in a common shower room used by 11 residents. Wet towels lay scattered across the shower floor.
The resident who first reported the problem was a man with bipolar disorder and anxiety who had been asking staff to address the unsanitary conditions since September. "Our common shower room is dirty with mold around it," he told inspectors. "I asked the housekeeping guy at the lobby to clean up and sanitize our shower room."
When he approached the director of nursing about the problem, she told him "there is no disinfectant available to clean up the shower room."
The mold persisted for weeks. On December 20, inspectors observed the contaminated shower room alongside a licensed practical nurse, who acknowledged the obvious: "The housekeeping is supposed to clean up and sanitize the shower room."
Other residents had grown frustrated with the deteriorating conditions. One told inspectors: "They need to clean up the shower room. Towels and linens were left in the shower room. Nobody is picking up."
A third resident was more direct: "They should clean up the mold in one south common shower room. They are not picking up the wet towels and linens from the shower room. We told the housekeeping, and they are not doing anything."
The director of nursing acknowledged to inspectors that residents deserved better. "Our housekeeping is supposed to sanitize the shower rooms," she said. "Residents should have a mold-free environment."
Yet the facility's own housekeeping director admitted the contamination had been allowed to fester. "The shower room in one south unit had mold for a few weeks, and it was brought to my attention," she told inspectors. "We ordered disinfectant and are waiting for it to come to clean the shower room."
The housekeeping director confirmed that the original complainant had approached her directly about the problem on a Thursday, but the mold remained when inspectors arrived days later.
Beyond the mold, the shower room suffered from additional maintenance failures. A broken hot water sink knob had gone unrepaired, leaving residents without access to hot water for handwashing. Both the licensed practical nurse and housekeeping director acknowledged that the maintenance department was responsible for the repair, but neither could explain why it remained broken.
The facility maintained written cleaning procedures that specifically required staff to "disinfect sink and shower, including pipes under the sink, mirror, and light above the mirror." These guidelines appeared to have been ignored entirely.
The administrator confirmed that all 11 residents living in the south unit were independent and relied on the common shower room for their bathing needs. This meant nearly a dozen people were forced to use contaminated facilities while staff claimed they lacked basic cleaning supplies.
The inspection revealed a breakdown at multiple levels of facility management. Housekeeping staff failed to maintain sanitary conditions. The nursing director offered excuses rather than solutions when residents complained. The maintenance department left essential fixtures broken. And facility leadership allowed the problems to compound for weeks.
Federal inspectors classified the violations as having minimal harm or potential for actual harm to residents, but the findings expose how basic environmental safety can deteriorate when nursing home staff fail to respond to resident concerns.
The resident who first reported the mold had intact cognitive abilities and was fully capable of advocating for himself and his fellow residents. His repeated attempts to get the shower room cleaned demonstrated the kind of self-advocacy that nursing homes should encourage and respond to promptly.
Instead, he encountered a system where the director of nursing claimed cleaning supplies were unavailable and housekeeping staff acknowledged problems but failed to act. The wet towels left on the shower floor suggested that residents continued using the contaminated space out of necessity, with no alternative bathing facilities available.
The facility's written policies promised proper disinfection of shower areas, but the reality was blackish mold covering four walls and broken fixtures that prevented residents from accessing hot water. The gap between policy and practice left 11 residents sharing a shower room that violated basic standards of cleanliness and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Berwyn from 2025-12-22 including all violations, facility responses, and corrective action plans.