Federal inspectors found these hygiene failures at Nexus at Alton during a September complaint investigation, documenting how certified nursing assistants provided incomplete incontinence care to residents who depend entirely on staff for toileting.
The first incident involved R7, a severely cognitively impaired resident with chronic obstructive pulmonary disease and diabetes who requires complete assistance with toileting. On September 25, CNA V19 removed R7's soiled brief containing urine and feces, then cleaned the resident's groins, labia, and perivaginal area with pre-moistened cloths.
V19 rolled R7 onto her side and cleaned the rectal area with multiple cloths, placed a new brief, had R7 roll to her back, then roll right to clean the right buttock before rolling back and fastening the brief.
Four minutes later, V19 told inspectors she had missed cleaning the left buttock because she was nervous.
The second case involved R13, a cognitively intact resident with congestive heart failure who requires supervision and assistance with toileting but remains always incontinent of bowel and bladder. On September 17, CNA V12 removed R13's urine-soiled brief and cleaned the resident's groins, labia, meatus, rectal area, and left buttocks with a wet soapy washcloth.
V12 used the same portion of the washcloth throughout the cleaning, failed to clean the right buttocks, and put on a new brief without drying R13.
The facility's own incontinence care policy, dated January 2025, requires staff to "clean peri area with appropriate cleanser and dry" and specifies that "cleansing should always be from front to back." The policy also mandates hand hygiene before and after the procedure.
Director of Nurses V2 acknowledged the problems during a September 24 interview with inspectors. "Staff should be doing complete incontinent care," V2 said. "Staff should have multiple towels so when you clean a dirty area you get a new towel and clean again. You need towels for rinsing and drying also."
Both residents affected by the incomplete care live with conditions that make proper hygiene critical. R7's diabetes increases infection risk, while both residents' complete dependence on staff for toileting means they cannot address hygiene problems themselves.
The violations occurred despite clear facility protocols. The incontinence care policy states that if a resident "needs more cleansing than above, a bath or shower may be given," indicating staff should provide thorough cleaning when standard procedures prove insufficient.
Federal regulations require nursing homes to provide appropriate care for residents who are incontinent to prevent urinary tract infections. The inspection found Nexus at Alton failed to meet this standard for two of three residents reviewed for incontinence care.
The missed cleaning and contaminated washcloth use represent basic hygiene failures that could expose vulnerable residents to preventable infections. R7's cognitive impairment means she cannot communicate discomfort or request additional cleaning, while R13's intact cognition means she likely experienced the inadequate care fully aware of what was happening.
Inspectors classified the violations as causing minimal harm or potential for actual harm to residents, affecting few people at the facility. The September 30 inspection was conducted in response to a complaint, though the specific nature of the complaint was not detailed in the report.
The facility operates at 3523 Wickenhauser in Alton and must submit a plan of correction to address the deficient incontinence care practices. Both residents remain dependent on the same staff who provided the incomplete hygiene care documented by federal inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Alton from 2025-09-30 including all violations, facility responses, and corrective action plans.