Nexus at Mascoutah: Catheter Care Failures Cause Harm - IL
Nobody clarified them. Nobody implemented them.
Two nurses told federal inspectors exactly that. The nurse identified as V2 said she and her colleagues did not view the urologist's written instructions as physician orders, so they were neither clarified nor carried out. A second nurse, V15, said the same thing. She told inspectors she would have expected nurses and aides to complete and document catheter care and fluid intake and output measurements as ordered.
She expected it. It didn't happen.
The urologist's instructions included repositioning the catheter tubing and drainage bag during turning and repositioning, specifically to prevent urine from flowing backward. That backflow is the mechanism behind catheter-associated infections, one of the most common and preventable complications for residents with indwelling catheters.
Inspectors classified the violation as causing actual harm to the resident.
The facility's own catheter care policy, last updated in April 2019, spells out the procedure in detail, from washing hands before starting to cleansing the insertion site and wiping the catheter in a single downward stroke. Its intake and output policy, dated June 2015, lists residents with indwelling catheters as automatically requiring output documentation.
Both policies were in place. The urologist had put the instructions in writing. Two nurses read them and concluded, independently, that the instructions didn't rise to the level of an order.
The inspection report does not describe what harm the resident suffered, only that harm occurred.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Nexus at Mascoutah in MASCOUTAH, IL was cited for violations during a health inspection on August 25, 2025.
Two nurses told federal inspectors exactly that.
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.