Health inspection·September 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include:R1 is a [AGE] year-old male, admitted in the facility on 03/21/22 with diagnoses of Type 2 Diabetes Mellitus without Complications; Unspecified Mood (Affective) Disorder; Opioid Use, Unspecified, Uncomplicated; Compression of Brain; Alcohol Abuse, Uncomplicated; Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter; and Personal History of Traumatic Brain Injury. MDS (Minimum Data Set) dated 06/21/25 documented R1's BIMS (Brief Interview for Mental Status) score is 11 which means moderate impairment in cognition. Facility's incident report dated 08/08/25 recorded: On 08/04/25 around 3:15 PM, R1 stated his roommate (R2) became upset about his closet space and became physical with him (R1). R1 was separated immediately and de-escalated. He (R1) stated the incident was unprovoked and didn't have any history of altercations with R2. R2 stated he thought his roommate (R1), was taking his belongings and he was looking for them in his (R1) closet. He (R2) did not find any of his personal belongings in R1's closet. R1 sustained a small cut inside his mouth. On 09/10/25 at 10:10 AM, R1 was in bed, taking a nap. R1 is alert and oriented, verbal, and able to ambulate without assistance. R1 was asked for any incident with R2 or previous roommate, or to any other resident in the facility. R1 stated, No, not that I know of. I did not have any altercation with any residents here. I was not hit. He (R2) did not hit me. There was no skin alteration in R1's mouth, lip or face as observed. R1 stated he does not have any problems with his mouth. On 09/10/25 at 9:56AM, R2 was observed in his room, sitting in a wheelchair. R2 is alert, oriented. He (R2) was asked regarding incident with R1 on 08/04/25. R2 verbalized, I didn't hit him (R1). I don't remember. I'm okay with other residents here. I don't remember having an altercation with other residents.R2 is a [AGE] year-old, male, admitted in the facility on 10/14/22 with diagnoses of Parkinson's Disease without Dyskinesia, without Mention of Fluctuations; Cognitive Communication Deficit; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizoaffective Disorder, Unspecified; and Brief Psychotic Disorder. MDS dated [DATE] recorded R2's BIMS score is 6, which means severe cognitive impairment. According to R2's care plan, he has history of aggressive/inappropriate behavior.On 09/10/25 at 10:52 AM, V6 Licensed Practical Nurse, LPN) was asked on what happened between R1 and R2 on 08/04/25 incident. V6 stated, I was at the nurses' station, I heard an argument. I went to see what was going on. When I entered the room, both (R1 and R2) were standing at the closet and were arguing. R2 swung his hand at R1. I tried to go between them. But R2 was able to hit R1 in the face. He (R1) had abrasion underneath the left eye with little bit of blood. I got him (R2) out of the room and called the CNA (Certified Nurse Assistant, CNA) to sit with him. I went back to room; I cleaned his (R1) abrasion. He didn't want to be touched and wanted to be left alone. I notified management, they Page 1 of 3 145070 145070 09/11/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few came. R2 was sent out for psych evaluation. R1 refused to be sent out, physician was notified. I regularly work with them, and both have no prior behavior. They (R1 and R2) were arguing over a closet space and missing items. There was a confusion about which space belongs to who.On 09/10/25 at 11:08AM, V7 (CNA) was also asked regarding R1 and R2. V7 verbalized, On 08/04/25, I helped the nurse with 1:1 (one on one) monitoring of R2. When I went there, they were quiet. I did not witness anything. V5 (Social Services Director/Assistant Administrator) was interviewed on 09/10/25 at 11:32 AM regarding R1 and R2 incident on 08/04/25. V5 stated, I was notified of the incident immediately by V6. She informed me that residents (R1 and R2) had physical altercation. She found R1 on the floor in the room stating that his roommate (R2) had hit him in the face. Upon that point, she (V6) did a body assessment, moved R2 out of the room and placed him on 1:1. R1 did have some blood in the mouth, left inner portion. It was like a little blood. He (R1) had explained that R2 stated that he (R1) had his (R2) clothing and that was the reason why he (R2) was aggressive with him (R1). R2 has history of delusional processes, usually he believes he's at home. This is the first time he(R2) showed aggression towards a resident. He (R2) did hit him (R1) but there were no major injuries. R1 refused to go to the hospital. Physician was notified. R1 is alert, oriented, ambulatory. No violent or aggressive behaviors in the past. R2 is alert to self and place. He's been here for almost two years. He wanders in the facility, delusional behavior believing he is at home, or he wants to go home. R2 had no prior aggressive behaviors. They were separated, R2 was sent out for psych evaluation and admitted for about two weeks. R1 was placed on well-being check for three days and no concerns. Upon return from hospital, R2 was placed to another room in the other side of the unit. He (R2) was also placed on well-being check for two days with no concerns. On 09/10/25 at 11:51 AM, V1 (Administrator) was asked regarding R1 and R2. V1 verbalized, I am the Abuse Coordinator. I was notified of the incident on 08/04/25 regarding R1 and R2's incident. I oversee the abuse investigation, V5 helps me with the investigation. I was notified of the alleged incident. Staff overheard a commotion. The one resident is confused, R2. He (R2) was agitated, thought his roommate was rummaging his clothes. They had words, pushing each other. No one saw what happened. Nurses responded. R1 had abrasion or skin tear in the mouth. R2 was put into a 1:1 monitoring and was sent out for psych evaluation. There was no major injury on R1. He (R1) was not sent out to the hospital, he refused. There were no prior aggressive behaviors on these two residents. At the time of incident, there was nothing else we can do.Based on interviews with V5 and V6, R2 was able to hit R1 in the face, sustaining abrasion under left eye and presence of small amount of blood in the mouth. V6 witnessed R1's and R2's verbal altercation and when R2 swung his hand at R1. R1's care plan on abuse documented in part but not limited to the following:Interventions: Staff will intervene when they observe R1 in a verbal altercation with peer to assist in de-escalation (08/08/25). Facility's policy titled Abuse Policy and Prevention Program 2022 dated 10-2022 documented in part but not limited to the following:Abuse Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. This purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by:Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment.This facility is committed to protecting our residents from abuse, neglect, exploitation, 145070 Page 2 of 3 145070 09/11/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0600 Level of Harm - Minimal harm or potential for actual harm misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Residents Affected - Few 145070 Page 3 of 3