Nexus At Mascoutah
Nexus at Mascoutah in MASCOUTAH, IL — inspection on August 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Policy: Elements of the Medication Order:1.
Medication orders specify the following: a.
Name of
or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified
order is documented in the resident's medical record with the date and signature of the person receiving the order.
The order is recorded on the physician order sheet in (EMR) and the MAR and TAR. 2.
The following steps are initiated to complete documentation: a.
Clarify the order, b.
Enter the orders with administration schedule in (EMR) and transmit to pharmacy.The facility's Catheter Irrigation: Indwelling policy, dated 6/2015, documented General: Catheter irrigation is done to ensure tube patency and remove clots or sediment from the catheter or bladder.
Responsible Party: RN, LPN.
Procedure: 1.
Obtain order from physician/nurse practitioner as to the type of solution and frequency of irrigation. 2.
Wash hands. 3.
Explain procedure to the resident. 4.
Provide privacy. 5.
Open irrigation set by grasping end flap and peeling back. 6.
Place irrigation set in convenient position.
Maintain sterility of drainage system.
Use only sterile solution or water for irrigation.
Type of solution should be specified in the order.
145785 08/25/2025
Nexus at Mascoutah 901 North Tenth Street Mascoutah, IL 62258
CNAs to reposition the urinary catheter tubing and bag during turning and repositioning to prevent the
on 8/4/25 as physician orders therefore they were not clarified nor implemented. V15 stated she did
document catheter care and I&Os as ordered.The facility's (Indwelling) Catheter Care policy, dated 4/2019, documented Policy: Daily and PRN catheter care will be done to promote comfort and cleanliness.
Equipment: The following equipment and supplies will be necessary when giving catheter care: 1.
Basin with warm water and soap/or pre-moistened disposable cloths. 2.
Personal protective equipment (i.e. gowns, gloves, etc.) as necessary. 3.
Towel and washcloth. 4.
Protective bed pad.
Procedure: 1.
Wash your hands before beginning the procedure. 2.
Assemble all equipment and supplies that will be necessary to perform the procedure. 3.
Knock before entering the room. 4.
Arrange the supplies so they can be easily reached. 5.
Identify yourself.
Explain procedure to resident.
It continues, 11.
Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes.
- Wash catheter itself by holding on to catheter at insertion site, wash with one stroke downward,
using same procedure for rinsing.
The facility's Intake and Output policy, dated 6/2015, documented General: Intake and/or output are monitored accurately to ensure adequate fluid balance for residents.
Responsible Party: all nursing staff.
Guideline: 1.
All staff can record the intake or output in the resident record. 2.
Intake is recorded for residents with the following: a.
Fluid restriction, b. IV therapy, c.
Tube feedings, d.
Order. 3.
Output is recorded for residents with the following: a. (indwelling) catheter, b.
Suprapubic catheters c.
Order.
145785 08/25/2025
Nexus at Mascoutah 901 North Tenth Street Mascoutah, IL 62258
proper PPE (personal protective equipment) while providing care for 2 of 3 (R1, R5) residents
8/18/25, documented R1 has diagnoses including rheumatoid arthritis, malnutrition, chronic fatigue, heart failure, altered mental status, neuromuscular dysfunction of bladder, cognitive communication deficit, hypertension, and acquired absence of right shoulder. R1's MDS (Minimum Data Set), dated 7/11/25, documented R1 is moderately cognitively impaired.R1's care plan, undated, documented R1 has an (indwelling urinary catheter) related to neurogenic bladder and is at risk of infection. R1's care plan also documented R1 requires enhanced barrier precautions with interventions including staff to wear gown and gloves when performing ADL'S (activities of daily living). On 8/18/25 at 8:38 AM R1 was observed in bed with her breakfast in front of her. R1's indwelling urinary catheter bag was uncovered and lying directly on the floor under the bed. V3, Care Plan Coordinator/LPN (Licensed Practical Nurse) walked in and stated to R1 where is your catheter bag? V3 then picked the catheter bag up off the floor, placed the bag in the bag cover, and attached it to R1's bed. V3 did not don gloves nor a gown prior to touching R1's catheter bag, catheter tubing, and R1's bed. R1's door was clearly marked with a sign noting enhanced barrier precautions and PPE (personal protective equipment) was readily available on R1's door caddy. 2.R5's admission Record document, print date of 8/18/25, documented R5 has diagnoses including multiple myeloma, ataxia following nontraumatic intracranial hemorrhage, polyneuropathy, glaucoma, hypertension, benign prostatic hyperplasia, and obstructive and reflux uropathy. R5's MDS, dated [DATE], documented R5 is moderately cognitively impaired although at time of interviews R5 was alert and oriented. R5's care plan, undated, documented R5 is at risk for complications related to receiving chemotherapy, R5 requires use of an indwelling catheter related to obstructive uropathy and is at risk of infection, and R5 requires enhanced barrier precautions (EBP) related to indwelling medical device. R5's care plan interventions include staff to wear gown and gloves when performing ADL's (activities of daily living) including when providing hygiene care. R5's physician orders, print date of 8/18/25, documented orders for enhanced barrier precautions for indwelling medical device urinary catheter.On 8/18/25 at 11:02 AM V6 CNA (Certified Nurse Assistant) and V9 CNA were observed as they provided indwelling urinary catheter care for R5.
V6 and V9 had the clean supplies set up on a bedside table covered with a clean towel although the clean gloves were off to the side of the towel and directly on the bedside table. R5's door to his room is clearly marked with enhanced precautions signs and PPE (personal protective equipment) including gowns was readily available on the isolation door supply caddy.
Neither V6 nor V9 donned gowns at any time during this observation. On 8/20/25 at 3:14 PM V1 Administrator stated she expects all facility staff to wear a gown and gloves when caring for residents on enhanced barrier precautions.The facility's Enhanced Barrier Precautions (EBP) policy, dated 10/6/22, documented Policy: Our facility employs the use of Enhanced Barrier Precautions to reduce transmission of MDROs (multi-drug resistant organisms) to staff hands and clothing that employs targeted gown and glove use during high-contact resident care activities. EBP are indicated for residents with any of the following: open wounds regardless of MRDO status, an indwelling medical device regardless of MDRO status, or colonization with a targeted MDRO.
Process: Staff utilize gown and gloves for high-contact resident care activities when residents require EBPL high contact activities may include: dressing, bathing, transferring, providing hygiene changing linens, changing briefs or assisting with toileting, device care or use of central line, urinary catheter, feeding tub, tracheostomy/ventilator, and would care.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.