Nexus at Mascoutah: Catheter Care Failures Harm Resident - IL
That was August 25, observed directly by inspectors at Nexus at Mascoutah, a nursing home at 901 North Tenth Street. The resident, identified in inspection records as R5, had an indwelling urinary catheter. Neither aide wore a gown during the procedure. One of them cleaned R5's penis, scrotum, and inner thighs but left the catheter tubing itself untouched. Then they turned him, and the urine backed up in the line.
The director of nursing, interviewed the same day, said she would expect aides to wear gowns and clean the catheter tubing. The assistant director of nursing said she expected staff to reposition the bag and tubing during any turning to prevent exactly what inspectors had just watched happen. Both said they expected it. Neither had caught it.
The inspection was triggered by a complaint and resulted in a finding of actual harm.
What inspectors found in R5's records made the August 25 observation look like the visible end of a much longer problem. His catheter care was supposed to be documented every shift. It wasn't recorded as completed on August 7, August 8, or August 15. His urine output was supposed to be monitored every shift as well. The output record, printed August 20, showed monitoring hadn't been documented on 17 separate shifts between July 22 and August 17, including July 22, 23, 27, 28, and 29, then again across the first three weeks of August.
His fluid intake, also ordered to be recorded every shift, went unlogged on at least 14 shifts between July 17 and August 15.
Seventeen shifts without documented urine output monitoring. Fourteen without fluid intake records. For a resident with an indwelling catheter, those numbers represent weeks of gaps in the basic surveillance that exists to catch infection, obstruction, and dehydration before they become emergencies. The inspection report classified the harm as actual, not potential.
There was also the matter of the urologist.
On August 4, a urologist left instructions for R5's care. The director of nursing told inspectors that she and the other nurses did not view those instructions as physician orders, so they were never clarified and never carried out. The assistant director of nursing said she didn't view them as orders either. The instructions sat unimplemented for weeks, until inspectors arrived and asked about them.
The facility's own catheter care policy, dated April 2019, lists gowns among the required personal protective equipment and describes a specific cleansing procedure that includes washing the catheter tubing itself with a downward stroke. The intake and output policy, dated June 2015, states that output must be recorded for any resident with an indwelling catheter. Both policies were in place. Neither was followed consistently, and neither failure was caught before a complaint brought inspectors to the door.
What the records show is a resident who needed careful, documented monitoring and received something considerably less. His catheter tubing went uncleaned during the observed care. His bag was left in a position that sent urine backward through the line. His output went unmonitored across stretches of days. A specialist's instructions were dismissed by nursing leadership as something other than orders. And through all of it, the documentation gaps that should have signaled a problem to supervisors were either missed or ignored.
The director of nursing and assistant director of nursing, when interviewed, described what proper care should look like with apparent confidence. What they could not explain was why it hadn't happened.
R5's catheter output record was printed on August 20. Five days later, inspectors watched urine flow the wrong direction in his tubing while two aides stood there without gowns, having never touched the catheter itself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Mascoutah from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
Nexus at Mascoutah in MASCOUTAH, IL was cited for violations during a health inspection on August 25, 2025.
That was August 25, observed directly by inspectors at Nexus at Mascoutah, a nursing home at 901 North Tenth Street.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.