Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Nexus at Berwyn
BERWYN, IL · 145 certified beds · Last Life Safety survey February 28, 2025
CMS Certification Number 145070 · first certified January 1967
Ownership
Operated by LEGACY HEALTHCARE · For profit - Corporation
- Ownership changed February 1, 2019 (change of ownership)to THE GROVE OF BERWYN from COURTYARD HEALTHCARE CENTER LLC
Position within IL
48 citations — more than 96% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 16 citations; the earlier surveys in the window averaged 16. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (January 2026 to April 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was February 2025. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Nexus at Berwyn
One email when it happens. No account; stop it any time with one click.
3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 48 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 48 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 48 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 2, 2022 | 16 |
| April 25, 2024 | 16 |
| February 28, 2025 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-02-28 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 3 | 2025-02-28 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 3 | 2025-02-28 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-02-28 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-02-28 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 2 | 2024-04-25 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2024-04-25 |
| K-0781 | Have restrictions on the use of portable space heaters. | 2 | 2025-02-28 |
What the citations cover
- Smoke Deficiencies 22
- Egress Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 5
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 22 |
| Egress Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 5 |
| Services Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 28, 2025 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 19, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 19, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 5, 2025) |
April 25, 2024 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 8, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 5, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0915 | Have proper power supply for life support equipment. | Waiver has been granted (March 4, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 2, 2024) |
December 2, 2022 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 22, 2022) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 22, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 22, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.