Nexus at Berwyn

In the surveyor’s words

From the most serious findings on record at Nexus at Berwyn, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 13, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Dec 30, 2025

  Based 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. […]

• Actual harm, isolatedF690Dec 12, 2025

  Based 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. […]

• Actual harm, isolatedF697Jul 1, 2025

  Based 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. Findings include: 1. […]

• Actual harm, isolatedF689Apr 17, 2025

  Based 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. […]