Health inspection·December 12, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to follow its grievance policy and resolve a grievance within 7 days for one resident (R33) out of three reviewed for grievances in a sample of 58.Findings include:On 12/9/25 at 1:40 PM, R33 stated that R33's green personal phone has been missing for several months. R33 stated that he made staff aware, and the facility has not replaced R33's phone as of yet. R33 stated that the only phone number he remembers is his own. R33 stated that all his family contacts were stored in his phone. On 12/12/2025 11:04 AM V1 (Administrator) stated that she is not familiar with R33 or his missing phone grievance as she has only been in this position for one month. V1 reviewed R33's grievance form dated 6/13/25. V1 stated that she will have to find out if R33 was present at the meeting held with family and if R33 also chose not to replace phone. V1 acknowledged that if R33 is his own responsible party and is the person that expressed his concern to V3 SSD (social services director), then R33 should have been involved with resolving his concern. On 12/12/25 at 11:45 AM, V3 SSD (social services director) stated that R33 informed V3 of missing phone in June 2025. V3 stated that R33 informed him to deal with R33's family member regarding phone since R33's family member is the one that bought phone for R33. When questioned where this is documented in R33's medical record or grievance form, V3 responded that this was not documented. When questioned what that implies, V3 responded if not documented, it was not done. When questioned if R33 was present at care plan meeting with R33's family when decision was made not to replace R33's phone, V3 responded that R33 was made aware of R33's family member's decision after the meeting but it was not documented. When questioned regarding R33 was not involved in the decision, V3 responded that he will telephone R33's family member to see if the family wishes to buy R33 a new phone. On 12/12/25 at 12:00 PM, V1 stated that V1 will buy R33 a new phone. V1 acknowledged that it is not the responsibility of R33's family to replace a phone that was lost in this facility. R33's grievance, dated 6/13/25, notes R33 lost his cellular phone, pay as you go - green. The resolution documented by V3 SSD (social services director) notes care plan with R33's family to discuss need of a replacement phone. Discussed options to replace phone. R33's family does not wish to replace.R33's BIMS (brief interview of mental status) score, dated 5/2/25, notes R33's score is 11 out of 15.R33's medical record notes R33 is his own responsible party. R33 does not have a guardian or power of attorney.R33's community survival skills evaluation, dated 4/27/25, notes R33 is not capable of independent pass to go out into the community.R33's medical record does not note R33 went out of facility at any time from 6/1/25 - 6/13/25.R33's admission inventory of belongings, dated 4/25/25, does not note if R33 had a cellular phone or not. It does note R33 has a blue duffle bag and did not want staff searching through it at the time of R33's admission. There is no further inventory of R33's belongings.The facility's grievances/concerns policy, revision 09/2024, notes a grievance must be answered within seven days is required. The department head is responsible for investigating the grievances or concern and speaking with Page 1 of 3 145070 145070 12/12/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0585 the resident who made the complaint regarding both the concern and possible resolution. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145070 Page 2 of 3 145070 12/12/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few 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. Brief interview for mental status dated 12/3/25 documents a score of eleven which indicates moderate cognitive impairment. Care plan initiated 8/28/25 documents: R101 has a urinary catheter. R101 will be free from catheter related trauma. Care per order. Physician order dated 10/13/25 documents change indwelling catheter and drainage bag when non-functioning. On 12/10/25 at 4:31pm, R10's indwelling catheter drainage tube was observed with white partials covered the entire inside of the tube with cloudy urine in the bag. R10 was unable to report when the last time his indwelling catheter had been changed. On 12/12/25 at 10:55am, V2 (Director of Nursing) said, an indwelling catheter orders have been changed from monthly to change as needed. An indwelling catheter should be changed if it leaks, if the insertion tube looks gunky, dirty or has stuff (partials) all over it. If the drainage tube looks cloudy with condensation (white partials) on the inside. Patient's insertion tube should be cleaned daily. On 12/12/25 at 11:36am, R101 indwelling catheter drainage tube was observed with white partials covered the entire inside of the tube with cloudy urine in the bag. V31 (nurse) said, R101's had condensation in the tube, and his urine is cloudy. On 12/12/25 at 11:44am, V2 said, R101's indwelling catheter tube is cloudy due to the medication he was taking. V2 said, R101's indwelling catheter can be changed. On 12/11/25 at 11:05am, V11 (Hospital Personnel) said, R101 was sent to the hospital with soiled linen, sitting in brown liquid that was foul smelling, with an indwelling catheter that was crusty around the insertion tube with cloudy urine drainage in the bag. Hospital paperwork dated 10/10/25 documents: R101 presented to emergency room with fever. Indwelling catheter in place draining cloudy urine noted in bag along with yellow crust around tubing and yellow tinge stains around diaper and linen. R101 also found to be lying in soaked linen and strong foul smelling liquid around perineal area. The Indwelling catheter was grossly soiled and wrapped up in the gluteal fold and around R101's leg. Had some purulence when removed. emergency room diagnosis: Urinary tract infection associated with indwelling urethral catheter. Foley changed in emergency department. Bladder scanned due to catheter having minimal output and tenderness noted to penis and lower abdominal, post void residue eight hundred and eighty-eight (888) milliliters. Adjusted indwelling catheter, output flow improved. Vancomycin started. Nursing note dated 10/11/25 documents: R101 was admitted with catheter associated urinary tract infection. Indwelling Catheter Care dated 9/2025 documents: daily and as needed (PRN) catheter care will be done to promote comfort and cleanliness. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. Being careful not to pull on catheter or advance further into urethra. 145070 Page 3 of 3