Nexus at Mascoutah: PPE Violations in Catheter Care - IL
Federal inspectors visiting Nexus at Mascoutah on August 18, 2025, found staff skipping required protective gear while handling urinary catheters for two residents who had been specifically flagged, in their care plans and by their physicians, as being at risk for infection.
The first resident, identified in inspection records only as R1, is a woman living with rheumatoid arthritis, malnutrition, heart failure, altered mental status, and a neurogenic bladder that requires a permanent indwelling urinary catheter. She is moderately cognitively impaired. Her care plan documented that staff must wear a gown and gloves during any hands-on care, including activities of daily living, because of her infection risk.
At 8:38 in the morning, inspectors observed R1 in bed with her breakfast tray in front of her. Her catheter drainage bag was not in its protective cover. It was lying directly on the floor beneath her bed.
A staff member identified as V3, a Licensed Practical Nurse who also serves as the facility's Care Plan Coordinator, walked into the room and asked R1 where her catheter bag was. Then V3 picked the bag up off the floor, put it in its cover, and attached it to the bed frame. She did not put on gloves. She did not put on a gown. She touched the catheter bag, the catheter tubing, and R1's bed with bare hands and unprotected clothing. The PPE she was supposed to wear was on the door caddy behind her.
The second resident, R5, is a man being treated for multiple myeloma who also has a permanent catheter, placed because of obstructive uropathy. His care plan documented infection risk related to both his catheter and his chemotherapy. His physician had written a formal order requiring enhanced barrier precautions for the catheter. His door was marked with precaution signs. Gowns were available on his isolation supply caddy.
At 11:02 that same morning, two certified nursing assistants, identified as V6 and V9, came to provide catheter care for R5. They had set up their clean supplies on the bedside table, covered with a clean towel, though even their clean gloves had been placed off the towel and directly on the bare table surface. They worked through the entire procedure without putting on gowns. Neither of them, at any point during the observation, reached for the gowns that were available outside the room.
Enhanced barrier precautions exist specifically to stop multi-drug resistant organisms from traveling from a resident's body or medical device onto a caregiver's hands and clothing, and then to the next room, the next resident, the next surface. The facility's own policy, dated October 2022, lists urinary catheter care explicitly among the high-contact activities that require gown and gloves every time.
On August 20, two days after inspectors watched both incidents, the facility's administrator told inspectors she expects all staff to wear gowns and gloves when caring for residents on enhanced barrier precautions.
What she expected and what inspectors saw were different things. The care plan was there. The physician order was there. The signs were on the doors. The gowns were on the caddies. None of it translated into the moment when V3 bent down and picked a catheter bag up off the floor with her bare hands, or the moment V6 and V9 moved through catheter care without reaching for the protective equipment hanging a few feet away.
For R1, already weakened by malnutrition, heart failure, and a compromised immune system, a catheter-associated infection is not an abstract risk. Her care plan said so in writing. For R5, undergoing chemotherapy for multiple myeloma, his body's ability to fight off any infection his caregivers might inadvertently carry in is already compromised. His physician said so in a formal order.
Inspectors classified the violations as causing minimal harm or potential for actual harm. The facility was cited under the federal standard requiring it to maintain safe and sanitary practices to prevent the spread of infection.
The catheter bag had been on the floor. The nurse picked it up. The gowns stayed on the door.
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: 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: October 6, 2026 · Our methodology
Nexus at Mascoutah in MASCOUTAH, IL was cited for violations during a health inspection on August 25, 2025.
She is moderately cognitively impaired.
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.