Health inspection·December 30, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. The Immediate Jeopardy began on 12/13/2025, the administrator was notified at 10:54AM on 12/23/2025 and the Immediate Jeopardy was corrected on 12/24/2025 when the facility moved all bed away from the heating register, completed in-services with all departments regarding keeping all beds away from the wall and checking on the bed position during rounds, and created a monitoring tool that is completed daily to check on the position of resident beds. Findings Include:R2 is a [AGE] year-old with the following diagnoses: burn of third degree of right upper arm, dementia, heat failure, and cerebrovascular disease.On 12/23/25 at 11:05AM, R2 was sitting in a wheelchair at the dining room table. A gauze wrap was covering R2's entire left arm. The gauze was clean and dry. A yellow-colored dried blister was on R2's right cheek bone that was about the size of a quarter. R2 was able to verify name but unable to answer any other questions due to mental status. In R2's room, the bed was about two feet away from the radiator heater with a floor mat on that side of the bed and another floor mat folded up in the corner. A bedside dresser was placed in between the bed and the wall. Two small metal brackets were noted on the radiator heater. The cover to the radiator heater was properly in place and not able to be moved by the surveyor. The radiator was not hot to touch.On 12/23/25 at 12:39PM, V5 (Maintenance Director) stated the facility uses a radiator heating system throughout the rooms where hot water passes through the radiators from a boiler. V5 reported each temperature is set on a thermostat on each floor. V5 stated each floor ‘s temperature is set from 76 to 78 depending on how cold it is outside. V5 denied having any issues with the radiators needing to be replaced or being too hot. V5 denied checking the radiators unless staff report an issue. V5 denied being aware of any burn's residents suffered from being against the radiator. V5 reported completing an in-service recently but could not remember the topic of what in-service was. V5 denied being aware of any staff telling V5 that R2 was burned after being against the radiator.On 12/23/25 at 1:48PM, V11 (Restorative Nurse) stated R2 had a fall on 12/6 that was confusion related due to a urinary tract infection. V11 reported on 12/13, R2 was attempting to get out of bed or stand and fell or rolled out the side. V11 stated R2 was transferred to the hospital then to another hospital to an in intensive care unit due to having burns on R2‘s body. V11 stated R2 had R2's bed up against the wall originally, but the bed was moved away from the wall after R2 suffered the burns. V11 reported R2 is confused and can follow basic instructions. V11 stated V11 was unaware why the bed was up against the wall and reported that is the way Page 1 of 5 145070 145070 12/30/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the rooms are set up. V11 stated R2 fell in between the bed and the wall and laid on the heating portion of the wall. V11 denied being aware of how long R2 was on the radiator for. V11 reported R2 needs one person assist with bed mobility and transfers. V11 stated R2 needs monitoring due to attempts to try to get out of bed unassisted.On 12/23/25 at 2:13PM, V5 stated V2 (DON) told V5 to complete the in-service on 12/13/25 with staff. V5 reported that V2 told V5 that R2 fell out of bed against the radiator. V5 stated that R2's dresser was put in between the bed and the wall to mitigate the risk of R2 falling onto the radiator again. V5 reported beds were also damaging the outlets and the radiator covers when the beds were too close by knocking them loose. V5 denied checking again if beds were against the radiators after the in-service was given.On 12/24/25 at 10:23AM, V3 (Assistant Director of Nursing/ADON) stated R2 has a wound on the right cheek bone that is closed that is partial thickness or a first-degree burn. V3 reported all of the wounds to the right arm and right leg are full thickness or third-degree burns. V3 stated there are burns to the right forearm, above the right elbow, right shoulder, right thigh, and right lower leg. V3 reported dressing changes are performed as ordered by the wound care physician, which R2 is seen by once a week. V3 reported since R2 is older with frail skin, the skin can be damaged easier. V3 stated the bed is now moved away from the wall and floor mats are in place. V3 was unaware why the bed was up against the wall originally. V3 denied R2 had any wounds before the fall on 12/13.On 12/24/25 at 11:00AM, V2 (DON) stated V2 was notified around 3 AM that R2 fell out of bed. V2 reported the nurse told V2 that R2 had some redness and discoloration so R2 was sent out to the hospital. V2 stated the nurse told V2 that R2 fell on the side of the bed where the radiator was located. V2 reported when the nurse called to get a follow up report the hospital notified the facility that V2 had some burns and would be being sent to another hospital to a burn unit. V2 stated R2 returned to the facility five days later. V2 reported some of the wounds were full thickness, and others were partial thickness. V2 stated an investigation was started, and it was found that R2 was burned on the radiator after the covering of the heater fell off when R2 fell. V2 reported the facility assumed R2 was lying directly on the exposed radiator, which explained why the burns were so severe. V2 stated R2 is only alert to self and cannot follow directions. V2 reported R2 is able to move around the bed and will attempt to stand unassisted but does so unsafely. V2 stated a floor mat was placed on each side of the bed and the bed was moved away from the radiator after the fall. V2 stated maintenance fixed the radiator by putting brackets on the cover to nail it back into the wall and an in-service was given to staff on moving the beds away from the radiator in order to not damage the cover.On 12/24/25 at 4:36PM, V12 (Nurse) stated R2 was lying in bed after being changed by the CNA around 2:30AM. V12 reported the nurse and CNA found R2 around 3AM lying on top of the radiator. V12 stated R2 has a cognitive impairment so R2 cannot use the call light. V12 stated staff went into the room after hearing a loud noise like something was falling. V12 reported R2 can move back-and-forth in the bed but cannot stand up or walk. V12 reported R2 is a high fall risk because R2 tries to get up alone and the week prior had a fall out of bed. V12 reported the bed was pushed against the wall because it is a small room, and this is the way all rooms are set up with two residents. V12 stated the CNA and V12 got R2 up from the side of the bed and during the assessment, V12 saw some redness to the right side of the arm and leg. V12 reported the radiator was a little bit off the wall, but V12 did not notice if R2 was lying directly on the radiator. V12 stated R2 was sent to the hospital and then will send to another hospital for burns. V12 reported R2's bed is now moved away from the wall.On 12/26/25 at 10:17AM, V20 (Wound Physician) a second-degree burn is basically a blister and when the blister opens, it becomes a third-degree burn. V20 reported a first-degree burn is basically like a sunburn. V2 stated all wounds to the right arm and 145070 Page 2 of 5 145070 12/30/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few right leg are 3rd degree burns. V20 reported V20 was not in the building when this occurred, but the wounds are consistent with falling directly onto a radiator. V20 stated the timeframe of how long R2 was on the radiator is unknown. V20 reported since R2 is older the skin is very frail and it would only take a few minutes for a third-degree burn to occur. V20 stated R2 also has psychosis and dementia, which would contribute to not feeling pain of skin burning. V20 reported normal people would have reacted and pulled away immediately, but R2 might not have been able to do that with an impaired cognition.A Rehab Nurse Practitioner note dated 11/28/25 documents R2 needed assistance with basic self-care tasks but remains limited in advanced activities of daily living and ambulation. R2 is at risk for high falls. Plan to follow all facility precautions, environmental safety, and therapy to improve balance.A Nursing note dated 12/7/25 documents the CNA found R2 on the floor mat next to R2's bed. No injuries were noted.A Nursing note dated 12/13/25 at 5:53AM documents R2 was found on the floor mat between the bed and the wall around 3:15AM. R2 was alert and oriented times one. A head to toe assessment was completed and abrasions and burns were noted to the right arm and leg.A Nursing note dated 12/13/25 at 11:30AM documents the nurse in the emergency department provided an update that R2 was transferred to another hospital to an intensive care unit.A Nursing note dated 12/18/25 documents R2 returned from the hospital's burn unit with a diagnosis of full thickness burns. Skin alterations were noted to the right face, right arm, and right thigh that were all burn related.The Hospital Records from the burn unit dated 12/13/25 documents R2 presented with 5% total body surface area deep partial thickness and full thickness burns to the right lateral arm and upper right thigh after a fall on a radiator for an unknown duration. R2 was found between the bed and the radiator per nursing home report. R2 was admitted to the burn intensive care unit. Dressings were ordered and applied. R2 was treated with dressings changes and monitored for fluid/electrolyte imbalances for five days until R2 was discharged back to the facility.The Fall Report dated 12/6/25 documents R2 had a fall where R2 was found next to R2's bed on the fall mat. No injuries were noted. Predisposing physiological factors are confused, impaired memory, gait imbalance, and incontinent.The Fall Risk Evaluation dated 12/7/25 documents a score of 20 indicating R2 is at high risk for falls due to decreased mobility, impaired memory, history of falls, and incontinence.The Fall Report dated 12/13/25 documents R2 was found around 3AM after a noise was heard coming from R2's room. R2 was lying on the side near the radiator and was immediately removed. The CNA last saw R2 around 2:30AM when R2 was changed. Redness was noted to the right leg and right arm. The physician ordered for R2 to go to the hospital. Predisposing physiological factors are confused, impaired memory, and gait imbalance.The Wound Physician note dated 12/22/25 documents R2 was seen for initial evaluation of wounds with multiple third degree burns in multiple areas of the body. The first wound to the right forearm is a full thickness/third degree burn that measured 36cm x 5.2cm x 0.1 cm. Adipose tissue was exposed. The wound bed was 40% granulation tissue and 40% slough. The second wound to the right shoulder is a full thickness/third degree burn that measured 0.9cm x 2.5cm x 0.1 cm. Adipose tissue was exposed. The wound bed was 40% granulation tissue and 40% slough. The third wound to the right lateral thigh is a full thickness/third degree burn that measured 22cm x 7cm x 0.1 cm. Adipose tissue was exposed. The wound bed was 30% granulation tissue and 60% slough. The fourth wound to the right anterior lower leg is a full thickness/third degree burn that measured 10.5cm x 6cm x 0.1 cm. The wound bed has no granulation, slough, eschar, or epithelialization present. Healing is expected to be delayed due to dementia and mobility.The Care Plan dated 1/11/23 documents R2 has impaired cognitive function/dementia or impaired thought processes daily related to or as evidenced by a diagnosis of dementia, low BIMS score of 0, and becoming easily confused. The Care Plan dated 12/18/25 documents R2 has an actual 145070 Page 3 of 5 145070 12/30/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few impairment to skin integrity to the right shoulder, right upper arm, right thigh, right lower leg, and right side of the face. R2 is at moderate risk for skin impairment based on Braden score of 15. An intervention includes to identify/document potential causative factors and eliminate/resolve where possible. The Care Plan that is undated documents R2 is a high risk for falls related to current medication use, poor safety awareness, unsteady gait, and dementia. Interventions include: bed bolster upon return 12/13/25, ensure the environment is made free of clutter and hazardous items are away from R2, and floor mats 12/13/15. The Care Plan that is undated documents R2 has impaired mobility related to diagnoses. R2 is on a transferring program. An intervention includes to use a wedge while in bed for positioning and comfort. This care plan also documents R2 has an ADL self-care performance deficit and impaired mobility related to dementia. An intervention includes that R1 requires 1 staff assistance to turn and reposition in bed.The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 00 (severe cognitive impairment). Section GG of the MDS documents R2 needs partial/moderate assistance with bed mobility where R2 does less than half the effort. The MDS dated [DATE] Section M documents R2 currently has burns that are second or third degree.An In-Service dated 12/13/25 documents V5 had an in-service on this day to discuss with staff to move beds off the wall and damage to heaters and outlets. This in-service was completed with 58 staff members from the nursing departments only.The policy titled, Fall Prevention and Management, dated 09/2025 documents, General: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe and environment as possible.On 12/26/25, the surveyor verified by observation, interview, and record review the facility implemented the following to correct the immediacy:Plan of Removal Affected resident corrective actions. A. Resident R2's bed was moved away from the wall and heating unit. Immediate Actions and Actions to prevent recurrence. (Initiated on 12/24/2025 at 12:30PM and will continue until all staff are in-serviced and trained prior to the start of their shift) The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. The Maintenance director/Designee completed rounds to ensure that all heating units are working adequately, and all beds are moved away from the heating unit/Wall. There was no concern identified. (This immediate action was initiated and was completed on 12/24/2025 at 12:30) B. All staff were provided with education by the Maintenance director/ Designee, training including but is not limited to ensuring the positioning of beds are away from the heating unit/Wall. (This immediate action was initiated and was completed on 12/24/2025 at 12:30pm) C. The Medical Director, Administrator, DON and Maintenance director reviewed the facility's policies which include but are not limited to: Guidelines on preventative maintenance measures, no revision requiredThis was initiated, reviewed and completed on 12/24/2025 at 12:30 pm D. New hires will be in-serviced by the Maintenance, or Designee.All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. E. The facility does not utilize agency staff however the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. F. The Maintenance director/ designee will conduct daily audits to identify any potential concerns related to this plan of removal. (This immediate action was initiated on 12/24/2025, daily for 4 weeks then weekly for 8 weeks.) G. During the weekends and holidays, the Maintenance director/Designee will conduct the daily audits, ensuring beds are away from the heating units. Any identified concern will be addressed immediately. (This immediate action was initiated on 12/24/2025 daily for 4 weeks then weekly for 8 weeks) H. 145070 Page 4 of 5 145070 12/30/2025 Nexus at Berwyn 3601 South Harlem Avenue Berwyn, IL 60402

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few To ensure compliance, the results of the audit will be reviewed daily during the meeting which is attended by the leadership which includes but is not limited to the: DON, ADON, Maintenance director and the Administrator/Designee. (This immediate action was initiated on 12/24/2025 daily for 4 weeks then weekly for 8 weeks) I. The Maintenance/Designee will conduct random staff interviews for at least 5 employees to gauge knowledge for retention and determine if additional training is required. (This immediate action was initiated on 12/24/2025 weekly for 12 weeks) J. Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI. The facility will reinforce the following process. K. All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance. (This immediate action was initiated on 12/24/2025, then weekly for 8 weeks) L. The Administrator, Maintenance director and Designee will monitor completion of this plan of 24, 2025 145070 Page 5 of 5