Nexus At Berwyn

Based 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.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, R6 then had her roommate call 911.On 1/28/2026 at 12:20 noon R1 said that R6 was feeling short of breath and coughing, she asks her to call 911 because V17 would not, telling her she was in hospice care, and it was not that bad to go to the hospital.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. If a hospice resident had a change in condition, I should call hospice care, she had a cough and did not appear short of breath, I did not call hospice or emergency transfer, I tried to give R6 cough medication she wanted to go to the hospital.On 1/29/2026 at 10:30am V2 (Director of Nursing-DON) said I expect hospice to be called if a resident has a change in condition, I expect the nurse to administer all as needed medications and use all interventions, and if a Resident is insisting on going to the hospital it is their right to be transferred.An admission record dated 1/27/2026 indicates that R6 admission date was 1/15/2026 and an advance directive of DNR/Comfort care, a diagnosis of chronic kidney disease, diabetes, Gastroesophageal reflux disease-GERD, acute embolism and thrombosis, anxiety, and malignant pericardial disease, A order summary report that indicates R6 had an order for benzoate capsule 200mg, dextromethorphan-guaiphenesin 5mg and ipratropium-albuterol 4 times a day for Shortness of Breath. A care plan dated 1/9/2026 for hospice care for a terminal diagnosis related to diagnosis of Dementia, 1/16/2026 with an intervention to coordinate care and services between facility caregivers and hospice company to ensure all residents needs are met. A progress note dated 1/13/2026 at 0708 resident admitted to local hospital SOB-Shortness of Breath. A progress note dated 1/12/2026 at 19:50 son call and inform that resident call 911 and going to local hospital. On 1/13/2026 a hospital records acute COPD-chronic obstructive pulmonary disease with bilateral wheezing present on presentation.Facility Policy: Resident Rights revision 9/2024General:The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/ or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference.Responsible party: All staffPolicy:It is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it endangers the health or safety of the resident or other residents.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/30/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Berwyn

3601 South Harlem Avenue Berwyn, IL 60402

SUMMARY STATEMENT OF DEFICIENCIES

Based 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. If a hospice resident had a change in condition, I should call hospice care, the physician and family, she had a cough and did not appear short of breath, I did not call hospice or emergency transfer, I tried to give R6 cough medication she wanted only wanted to go to the hospital.On 1/29/2026 at 10:30am V2 (Director of Nursing-DON) said I expect hospice to be called if a resident has a change in condition, physician and family.An admission record dated 1/27/2026 indicates that R6 admission date was 1/15/2026 and an advance directive of DNR/Comfort care, a diagnosis of chronic kidney disease, diabetes, Gastroesophageal reflux disease-GERD, acute embolism and thrombosis, anxiety, and malignant pericardial disease, An order summary report that indicates R6 had an order for benzoate capsule 200mg, dextromethorphan-guaiphenesin 5mg and ipratropium-albuterol 4 times a day for Shortness of Breath. A care plan dated 1/9/2026 for hospice care for a terminal diagnosis related to diagnosis of Dementia, 1/16/2026 with an intervention to coordinate care and services between facility caregivers and hospice company to ensure all residents needs are met. A progress note dated 1/13/2026 at 0708 resident admitted to local hospital SOB-Shortness of Breath. A progress note dated 1/12/2026 at 19:50 son called and informed the facility that R6 called 911 and will be going to local hospital.Facility Policy: Change on Resident Condition 9/2025General:It is the facility policy, except in a medical emergency, to alert the resident, resident's physician and residents responsible party of a change in condition.Responsible Party:RN, LPN, Social ServicesPolicy:Nursing will notify the resident's physician or nurse practitioner when: B.

There is a significant change in the residents' physical, mental or emotional status. D.

The resident wants to be discharged or leaves AMA. E. It is deemed necessary or appropriate in the best interest of the residents.

Hospice: 9/2024General: To provide guidance on how hospice services will be administered within the facility.Purpose: Ensure that the hospice services meet the professional standards and principles that apply to individuals who provide services in the facility and to the timeliness of the services.Protocol:5.

A provision that LTC facility immediately notifies the hospice about the following:a. A significant change in residents' physical, mental social , or emotional status.c. A need to transfer the resident from the facility for any condition.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/30/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Berwyn

3601 South Harlem Avenue Berwyn, IL 60402

SUMMARY STATEMENT OF DEFICIENCIES

Keep residents' personal and medical records private and confidential.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.

Findings include:On 1/27/26, at 12:35PM, observed a report sheet on top of medication cart on the 1st floor north hallway, with R9 and R10 health information visible and uncovered. On 1/27/26 at 12:35PM, V7 (Certified Nurse Aide) made aware of findings and verified that the form does contain resident's information, the nurse on duty left to lunch. V7 said it contains information of two residents. V7 said she is not sure if the report should be placed on top of cart visible to others.On 1/27/26 at 12:50PM, V2 (Director of Nursing) made aware of above findings and verified that the report form on top of nurse's cart does contain resident information and should not be visible on cart for resident privacy. On 1/29/26 at 10:39AM, V3 (Asst.

Administrator) said that resident records containing medical information should not be visible to other residents or visitors, all records should be covered to maintain privacy. V3 said the only policy on HIPAA is in the employee handbook.R9 was admitted on [DATE], with diagnoses listed in part but not limited to primary osteoarthritis, other specified site, type 2 diabetes mellitus without complications, acute and chronic respiratory failure with hypoxia, insomnia, due to other mental disorder, acute bronchitis, gastro-esophageal reflux disease without esophagitis, anemia, hyperlipidemia, bipolar disorder, depression, polyneuropathy, essential hypertension and atrial fibrillation. R10 was admitted on [DATE], with diagnoses listed in part but not limited to heart failure, pneumonia, atrioventricular block, type2 diabetes mellitus without complications, essential hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, muscle weakness, abnormal posture, dysphagia.

Facility Policy on Resident Rights/ HIPAA/ Abuse and Neglect-Employee Handbook page 13 of 93. HIPAAThe facility treats as confidential residents medical and health information in accordance with the federal Health Insurance Portability and Accountability Act ( HIPAA) and its Standards for Privacy of Individually Identifiable Health Information ( Privacy Rule).

The Privacy Rule requires the Facility to maintain the confidentiality of such medical records and other health information (referred to as protected health information or PHI) and defines and limits when and how PHI may be used or disclosed by the Facility, employees will have access to PHI.

Employees must not use or disclose PHI, either directly or through others, in any manner that would violate the Privacy Rule.

Any employee found to have violated HIPAA will be subject to disciplinary action, up to and immediate termination.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/30/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Nexus at Berwyn

3601 South Harlem Avenue Berwyn, IL 60402

SUMMARY STATEMENT OF DEFICIENCIES

Based 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.Findings include:On 1/28/2026 at 12:30pm this writer, V15(Rehabilitation Aide) and V16(Certified Nursing Assistant-CNA) observed R8 in bed with a urine soaked depend on causing the depend to separate when attempting to remove.On 1/28/2026 at 12:35pm V16 said that she's the CNA for R8 who is dependent on all care from staff, and she does resident rounds before breakfast and after lunch and that she has not made any rounds for R8 because V15 had made rounds earlier.On 1/28/2026 at 12:40pm V15 said she did incontinence care on R8 at 7:30am only, and that resident's rounds are every two hours and as needed, she assist the staff with morning care only.On 1/28/2026 at 1:30pm V2 (Director of Nursing-DON) said that she expects the CNA and nursing staff to do rounds every two hours and as needed, especially for dependent residents.An admission record dated 1/28/2026 indicates that R8 has a diagnosis of Alzheimer disease, encounter for palliative care, dysphagia. An order summary report for hospice care DX.

Alzheimer's disease dated 4/22/2024. A care plan dated 11/7/2024 for potential for impairment to skin integrity with an intervention to keep skin clean an dry perform prompt toileting/incontinence care.Facility Policy: Activities of Daily Living Dependent Residents. 8/2024General A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis.Purpose: To ensure that dependent residents in the facility receive regular, safe, and respectful bathing assistance as part of their activities of daily living (ADL's), in alignment with their care plan, preferences, and clinical needs.Definition.

Dependent resident: A resident who requires physical assistance or total care to complete the task bathing ADLs: Activities of daily living such as bathing, dressing, toileting, eating and mobility.Responsible Party:All nursing staff, certified nursing assistants (CNAs), and any other personnel involved in direct resident care.

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