Health inspection·June 9, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based 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. Findings include: On 06/04/25 at 10:13am, the treatment cart noted in the hallway unlocked and unattended to by Room105. V7 LPN (Wound Care Nurse) confirm that it was the treatment cart stating that it is the treatment cart with treatment medications. V7 stated that the facility policy is to have it locked when not at eyesight level and not in use. At 10:40am, V2 (DON) stated that the treatment cart should be locked when not in visual contact of the nurse. V2 stated that V7 (treatment nurse) has told me about it (not locking the cart). I told her lock to the cart always when not in the eye contact with the cart. On 06/04/25 at 11:24am, crash cart noted in the hallway in front of the elevator unlocked with two plastic locks broken and left on the crash cart. When shown to V20 LPN (Licensed Practical Nurse). V20 stated the cart should be locked always with the red plastic lock so that no one can get into it. V20 stated I did not use the cart this morning and it should be locked; I turned the gray lock but that can be easily turned to unlock. The lock is to make sure that no one can get into its residents /visitors. On 06/05/25 at 11:03pm, R3 noted in the room in bed at the bedside noted 3pills in the medication cup at the bed side. R3 was unable to identify the pills. At 11:09am, from the hallway noted R11 had medication cup on the over bed side table. Upon entering the room there were 8pills noted in the medication cup. R11 stated that the nurse (referring to V9 (LPN) gave him the medications this morning and will have to take it later. At 11:11am, When the surveyor observations were shown to V9 LPN (Licensed Practical Nurse) and was asked about the facility policy for medication pass. V9 stated that the medications for R11 was this morning medication and while having conversation with R11 she forgot to give them to R11 and make sure he took them (Medicine). V9 stated that she should not have signed the MAR (Medication Page 1 of 4 145070 145070 06/09/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0761 administration Record) has given. Level of Harm - Minimal harm or potential for actual harm V9 checked the POS and the MAR with the surveyor R3's medication that was left at the bedside and told the surveyor that the medication found at R3 bedside is not left on the side table dresser by her and did not know how R3 got the medicines. V9 stated the medications look like tums and stool softener but R3 did not have any order for the medicines. And they should not be left at bedside unless ordered by the doctor to do so. Residents Affected - Few On 06/05/25 at 11:24am, V10 (Nurse Supervisor) stated that we (nurses) not supposed to leave medication at bedside unless ordered by the doctor and the medication should not be signed out as given until after the resident has taken the medication. At 11:42am, V3 ADON (Assistant Director of Nurse's) stated that he cannot for word for word quote the facility policy, but the expectation is for the nurses to follow administration policy and one of it is to observe the patient (resident) take the medicine (Swallow) a document right after it is taken. V3 stated that no medication should be stored at bedside without an order and resident assessment that resident can self-administer. The facility policy on Crash Cart presented with revised date 04/2025 documented that in general the policy is to provide the staff with guidance on Crash cart contents and monitoring. Listed purpose indicated that the Crash Carts are set up for type of life-threatening event expected to occur in this facility (i.e., cardiac, anaphylaxis). Protocol listed includes crash cart will be checked daily by night nurse and department manager; verify the crash cart has not been opened since the previous day by verifying tag number against crash cart checklist. The facility policy Self-Administration of Medications and treatments presented with review date 12/2021 documented that self-administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. Facility policy on Medication Storage in the Facility presented with review date 6/2024 documented in general that medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Responsible party listed nursing. Listed procedure includes but not limited to medication carts and medical supplies are locked or attended by person with authorized access that includes licensed nurses. Facility policy on Medication Administration presented with review date 3/2022 documented in general that all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of responsible party are RN (Registered Nurse), LPN (Licensed Practical Nurse). Listed guidelines includes but not limited to remain with the resident to ensure that the resident swallows the medications. 145070 Page 2 of 4 145070 06/09/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: On 06/04/25 from 10:13am to 11:30am, the following observations were made: At 10:23am, R7's clothing noted on the bare floor R7 stated they are dirty clothes and stated he has no plastic bag to put the clothes Complain of not having toilet paper in the toilet for days at a time. At 10:42am, on the 1st floor, 1 south room [ROOM NUMBER], room floor noted with yellowish dry colored particles and orange peels. At 10:47am, V15 CNA stated the resident must have spill something, its dry possibly from previous shift. I am the CNA for this morning and the floor has been like that. On the 3floor at 10:54am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. At 10:56am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. At 10:58am, room [ROOM NUMBER], noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. In the same room garbage can with overflowing garbage and used adult incontinent diaper. room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. When all these observations were shown to V16 LPN (Licensed Practical Nurse) she stated that the housekeeping are responsible for replacing the toilet tissue and hopefully they will be getting to it, most of the garbage in the can are not from this shift. The surveyor asked who takes care of the garbage, V16 stated the housekeeping staff but those incontinent diapers should not be left in the room garbage. 06/04/25 at 11:03am, V18 (Housekeeping Director) stated that I (18) came in late this morning, but the rooms are supposed to be cleaned daily, and they are on it now. As for the toilet papers they (Housekeeping staff) are stocking up now. In no time now, all the rooms will be stocked. At 11:22am, in room [ROOM NUMBER] observed no tissue in the bathroom toilet. R4 noted sitting on 145070 Page 3 of 4 145070 06/09/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the edge of the bed. R4 stated for two days now there was no tissue in the bathroom. They (housekeeping staff) came to clean it up but there is no tissue left. I don't know how they want us to wipe off our butt. room [ROOM NUMBER] shared the same bathroom with room [ROOM NUMBER]. On 06/04/25 at 2:06pm, V12 LPN (Licensed Practical Nurse) stated that the housekeeping staff usually are responsible for placing new tissue in the toilet room (washroom). V12 stated no extra tissue papers (rolls) are kept here (Nurse's station) but there should be plastic bags for room cabbage cans left at the Nurse's station. On 06/05/25 at 9:36am, V18 (Housekeeping Director) stated that the housekeepers are to stock up supplies during the cart preparations. The housekeeper for each floor is to stock up the rooms daily in the morning but sometimes they do and sometimes they do not. At times when budget run over it depends then I will put only one roll in the room. On weekends we leave supplies for the staff because I don't work on weekends. V18 stated I (V18) leave it on Friday before I leave. There are 96rolls in each box. The residents are not supposed to run short of toilet rolls, every room must have a supply very day. the surveyor asked do the staff that includes nursing staff have access to where toilet supplies are always kept. V18 stated only the housekeeping staff have access to the housekeeping storage unless there is a manager in the building. The surveyor then asked whether it Is appropriate for residents to be out of toilet tissue and what other plans are in place for them to clean up after using the bathroom. V18 stated logically they can use the towel (cloth towels) to wipe. V18 stated they (towels) are not stock in the bathroom for that purpose. 0n 06/05/25 at 1:49pm, V18 stated that there is no standard policy or SOP (Standard of Operation) given to us by the company, the only thing I (V18) have is the daily housekeeping check list from the hold company. Since the name change I (V18) don't have any policy on housekeeping from the new company. On 06/05/25 at 3:40pm V1 stated that the housekeeping keys will be left at the front desk so there should be no problem with the toilet roils any more, I know we should do better. We have problem with staff taken them home, we will do better. 145070 Page 4 of 4