Nexus at Mascoutah

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of resident medications in 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7. This past non-compliance occurred on 6/2/26 with a correction date of 6/2/26. Findings Include:1) R1's Face Sheet, undated, documents R1, in part, has the following diagnosis: Osteomyelitis, Malignant Neoplasm of the Endometrium, Pain in Bilateral Feet, Neuropathy, and OA (Osteoarthritis). R1's MDS (Minimum Data Set), dated 5/27/26, documents R1 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R1 is cognitively intact. R1's Care Plan, dated 5/4/23, documents R1 is at risk for abuse. R1's Progress Note, dated 6/2/26 9:00 PM, documents the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly clean an indwelling urinary catheter, failed to complete and document indwelling catheter care as ordered, failed to verify an indwelling urinary catheter flush order, failed to monitor intake and output as ordered, and failed to ensure a resident's indwelling was properly positioned and covered for 3 of 3 residents (R1, R2, R5) reviewed for indwelling urinary catheters in the sample of 11. These failures caused R2 to experience increased pain and sepsis secondary to developing a catheter associated urinary tract infection. Findings Include:1. [...]

Inspectors wroteBased on record review and interview, the facility failed to verify and implement a consultant physician's instructions, failed to follow hospital discharge orders for normal saline indwelling urinary catheter flushes, and failed to document a resident's response to antibiotics for 1 of 3 residents (R2) reviewed for quality of care in the sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facilities policy and don proper PPE (personal protective equipment) while providing care for 2 of 3 (R1, R5) residents reviewed for indwelling urinary catheter in the sample of 11. 1. R1's admission Record, print date of 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean linen carts were kept covered and protected from contaminates. This failure has to potential to affect all 51 residents who reside at the facility.

Inspectors wroteBased on interview and record review the facility failed to address residents needs by answering call lights in a timely manner for 4 of 5 residents (R1, R3, R4, and R6) reviewed for call lights in a sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care in a timely manner to promote resident's dignity for 3 of 5 residents (R1, R2, and R5) reviewed for dignity in a sample of 5. This failure resulted in R2 having feelings of frustration due to soiling herself and being left on a bedpan for 29 minutes and reporting pain related to this.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent an employee from misappropriating narcotic pain medication for 2 of 3 residents (R2, R3) reviewed for misappropriation of property in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure progressive fall interventions were in place and staff were aware of these interventions for 1 of 4 residents (R5) reviewed for falls in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident rights were respected regarding a social media post for 1 (R2) of 3 residents in a sample of 3. R2's Undated Face Sheet, documents R2 was initially admitted to the facility on [DATE] with diagnoses including pain, generalized anxiety disorder and mild cognitive impairment. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents resident is alert. On 3/28/2025 at 9:32 AM V1, Administrator stated she recently received an anonymous call on Monday morning 3/24/2025, the call ID was blocked, and the caller reported that (V5), LPN (Licensed Practical Nurse) posted on social media talking about a resident and the anonymous caller sent screen shots of the social media post to V1. She stated no residents or facility name was listed in the post. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure progressive interventions were being implemented for 1 of 3 residents (R2) reviewed for falls in the sample of 6.

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview, observation and record review, the facility failed to perform proper hand hygiene and/or the wearing of gloves while plating food and failed to check and maintain the temperatures of the food, including all diets (regular diets, special diets, and pureed foods), prior to serving the residents to prevent contamination and foodborne illness. This failure has the potential to affect all 50 residents living in the facility.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to promote a pest free environment by not removing flies from resident's rooms for 6 out of 6 residents, (R6, R103, R13, R46, R22, R11), reviewed for pest control in a sample of 41.

Inspectors wroteBased on interview and observation, the facility failed to properly administer medications to residents, including interpreting prescriber's order and ensuring the resident receives their medications, to meet their needs for 4 of 5 residents (R22, R33, R38, R103) reviewed for medication administration in the sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medication from the medication room refrigerator, restock the medication shelf, and medication cart.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide 80 square feet of floor space per resident bed for 9 of 50 residents (R5, R11, R15, R19, R20, R22, R32, R33, and R103) reviewed for room size in the sample of 41.

Inspectors wroteBased on interview, observation, and record review the facility failed to promote respect and dignity in an environment that promotes maintenance by not providing timely removal of urine and feces from a resident's bedside commode for 1 of 1 resident (R11) reviewed for dignity in a sample of 41.

Inspectors wroteBased on interview and record review the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) of Non-coverage for 1 of 3 (R6) reviewed for Beneficiary Notice in the sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing of the involuntary discharge and opportunity for appeal for 1 of 1 residents (R51) and no written notification was sent to the family for 1 of 1 residents (R9) reviewed for discharge in a sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing of the voluntary discharge and bed hold notice for 1 of 1 residents (R51) reviewed for discharge in a sample of 41 On 08/06/24 02:28 PM, admission profile undated documents admission on [DATE]. R51's Progress note, dated 5/27/2024 at 6:39 pm, documented Resident arrived at facility via EMS (Emergency Medical Services). A&O (alert and oriented) x4 and able to let needs be known to staff. Resident cont (continent) of b&b (bowel and bladder). No c/o (complaints of) pain or discomfort. Respiration even and non-labored. BS (bowel sounds) active. Resident oriented to room and use of call light. R51's Progress note dated 5/28/24 at 8:35 am documented Patient was in 08/06/24 01:54 PM pain and rated it a 14 on a scale of 0-10. [...]

Inspectors wroteBased on interview and record review the facility failed to follow nurse practitioner recommendations in a timely manner for 1 of 41 (R35) residents reviewed for quality of care in a sample size of 41.

Inspectors wroteBased on interview, observation, and record, review, the facility failed to use appropriate safety procedures to assure resident safety during transfer for 1 of 3 (R5) reviewed for resident safety in the sample of 41.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete incontinent care for 1 of 5 residents (R5) reviewed for incontinence care in the sample of 41.

Inspectors wroteBased on interview and record review, the Facility failed to ensure an environment free from abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. This Failure caused R1 to be fearful of R2 and causes her to have trouble sleeping.

Inspectors wroteBased on interview and record review, the Facility failed to report allegations of abuse in 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on interview and record review, the Facility failed to investigate an allegation of sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.

Inspectors wroteBased on Observation, Interview, and Record Review, the facility failed to provide ice water to 2 (R2 and R3) of 3 residents, at risk for dehydration, in the sample of 9. Findings Include: R2's Face Sheet documents an admission date of 1/26/2024. Diagnosis include Type 2 Diabetes, Diabetic Retinopathy, Respiratory Failure with Hypoxia, Obesity, Schizophrenia. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent on staff for toileting, showering, dressing, uses wheelchair. Is always incontinent of bowel and bladder. R2's Care Plan dated 1/26/2024 documents Hydration: R2 is At risk for alteration in fluid volume related to history of dehydration. Interventions include: Encourage fluid intake. Keep fresh water in reach of R2. On 3/28/2024 at 8:30AM, R2's water pitcher was empty. R3's Face Sheet documents an admission date of 1/2/2023. [...]

Inspectors wroteThe Facility failed to ensure a bruise of unknown origin was investigated and the appropriate corrective actions were initiated for 1 of 3 residents (R2) reviewed for injuries in the sample of 9.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for transfers in the sample of 9. This failure resulted in R2 being picked up by staff after a fall and transferred to a chair and sent out to the hospital later where she sustained a tibia spiral fracture.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were not being physically abused for 1 of 3 residents (R1) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for 4 of 5 residents (R4, R13, R38, R102) reviewed for abuse in the sample of 43. This failure resulted R102 who is demented being fondled by R38 in the dining room and a reasonable person would not want to be sexually fondled/abused.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 53 residents living in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to provide 80 square feet of floor space per resident bed for 10 of 53 residents (R6, R17, R18, R20, R27, R28, R30, R200, R201 and R202) reviewed for room size in the sample of 43.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to conduct ongoing assessment and monitoring of a resident with significant weight loss for 1 of 5 residents (R12)reviewed for nutrition in the sample of 26. This failure resulted in continued weight loss for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner which prevents potential contamination. This has the potential to affect all 48 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review, the Facility failed to provide 80 square feet of floor space per resident in multiple resident bedrooms for 10 of 10 residents (R6, R7, R13, R19, R35, R37, R46, R47, R247, and R248) reviewed for floor space in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to maintain a clean and clutter-free environment for 3 of 4 residents (R6, R19, R47) reviewed for homelike environment in the sample of 26.

Inspectors wroteBased on interview, record review, and observation the facility failed to provide pressure ulcer treatments as ordered for one of five residents (R20) reviewed for pressure ulcers in the sample of 26. Findings Include: R20's Minimum Data Set (MDS) dated [DATE] documents R20 is severely cognitively impaired. R20's Physician Order Sheet (POS) dated 7/13/22 documents apply to Coccyx Dakin's solution (Sodium Hypochlorite) apply topically one time a day for wound care. Cleanse the wound with wound cleanser soak gauze in Dakin's and pack the wound leave for twenty minutes then remove packing. Then apply Silvadene, Gentamycin and Calcium Alginate cover with an abdominal bandage. R20's POS dated 8/31/22 documents cleanse coccyx with soap and water, NS (Normal Saline) or wound cleanser apply SSD (silver sulfadiazine) cream, cover with collagen powder and calcium alginate and dry dressing. [...]