Nexus at Berwyn
3601 South Harlem Avenue · Berwyn, IL · 60402 · 7087494160
145 certified beds For profit - Corporation Chain: Legacy Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $288,014 in fines in the last 24 months.
- 7 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$288,014 in federal fines in the last 24 months
4 fines — CMS fines are reserved for verified, serious non-compliance.
61% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.12 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.49 | 0.55–0.75 |
| Weekend hours / resident-day | 2.69 | ≈ weekday level |
| Nursing turnover / year | 61% | median 45% |
| Fines (3-yr window) | 5 · $428,544 |
Inspection citations (52 in the current record)
-
Immediate jeopardy · J March 13, 2026 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected March 14, 2026 · Quality of Life and Care
-
Potential for harm · D January 30, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 31, 2026 · Resident Rights
-
Potential for harm · D January 30, 2026 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected January 31, 2026 · Resident Rights
-
Potential for harm · D January 30, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 31, 2026 · Resident Rights
-
Potential for harm · D January 30, 2026 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected January 31, 2026 · Resident Rights
-
Potential for harm · D January 30, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 31, 2026 · Quality of Life and Care
-
Immediate jeopardy · J December 30, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 31, 2025 · Quality of Life and Care
-
Potential for harm · E December 22, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected December 23, 2025 · Environmental
-
Actual harm · G December 12, 2025 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 13, 2025 · Quality of Life and Care
-
Potential for harm · D December 12, 2025 · found via complaint
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.
Corrected December 13, 2025 · Resident Rights
-
Potential for harm · E September 30, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 3, 2025 · Quality of Life and Care
-
Potential for harm · D September 11, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G July 1, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected July 2, 2025 · Quality of Life and Care
-
Potential for harm · D July 1, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 2, 2025 · Quality of Life and Care
-
Potential for harm · D June 9, 2025 · found via complaint
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.
Corrected June 10, 2025 · Pharmacy Service
-
Potential for harm · E June 9, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected June 10, 2025 · Environmental
-
Actual harm · G April 17, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 18, 2025 · Quality of Life and Care
-
Potential for harm · D March 22, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 24, 2025 · Quality of Life and Care
-
Potential for harm · D February 28, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected March 3, 2025 · Resident Rights
-
Potential for harm · D February 28, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 3, 2025 · Quality of Life and Care
-
Potential for harm · D February 28, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected March 3, 2025 · Quality of Life and Care
-
Potential for harm · D February 28, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected March 3, 2025 · Pharmacy Service
-
Potential for harm · E February 28, 2025
Provide and implement an infection prevention and control program.
Corrected March 3, 2025 · Infection Control
-
Potential for harm · D February 28, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 3, 2025 · Quality of Life and Care
-
Potential for harm · D February 28, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 3, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 13, 2026 | Fine | $128,550 |
| December 12, 2025 | Fine | $135,690 |
| December 12, 2025 | Payment Denial | 16 days |
| July 1, 2025 | Fine | $11,349 |
| January 16, 2025 | Fine | $12,425 |
| April 12, 2024 | Fine | $140,530 |
| April 12, 2024 | Payment Denial | 74 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145070 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.