Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nexus At Mascoutah during CMS and state inspections, most recent first.
Surveyors found that appropriate care was not provided for residents regarding bowel and bladder continence, catheter management, and UTI prevention, resulting in a deficiency.
Staff failed to follow the facility's Enhanced Barrier Precautions policy by not donning required gowns and gloves while providing care to two residents with indwelling urinary catheters. In both cases, staff interacted with catheter equipment and performed care activities without appropriate PPE, despite clear signage and available supplies, contrary to the residents' care plans and facility policy.
Multiple residents dependent on staff for toileting assistance experienced significant delays in call light responses, with one resident left on a bedpan for nearly half an hour, resulting in pain and skin redness. Other residents reported similar delays, leading to feelings of frustration and lack of dignity. Staff acknowledged the importance of prompt care, but cited staffing shortages as a factor. Facility policies emphasized timely care, but these were not followed as observed.
An LPN misappropriated hydrocodone-acetaminophen prescribed to two cognitively impaired residents by documenting administration on narcotic count sheets but not on MARs, taking the medication for personal use. The discrepancy was discovered when another nurse noticed unusual documentation and pill count reductions, leading to an internal investigation and the LPN's admission of theft.
A resident with significant cognitive and mobility impairments, identified as high risk for falls, did not consistently receive prescribed fall prevention interventions such as grippy socks and a non-slip mat. Staff were unaware of these interventions, and the resident experienced multiple falls, including one with injury, indicating a failure to implement and communicate care plan updates.
A facility failed to respect a resident's privacy and dignity when an LPN posted a social media comment describing a resident with identifiable characteristics. Although the post did not name the resident or facility, staff recognized it as referring to a specific resident, who expressed that such posts would hurt his feelings. The facility's policies prohibit disrespectful comments about residents, highlighting a breach of these standards.
A resident with a complex medical history experienced multiple falls without new preventive measures being implemented. The facility failed to update the care plan with progressive interventions after each fall, despite acknowledging the need for new strategies. Staff interviews confirmed the oversight, which did not align with the facility's fall prevention policy.
Two residents were involved in an incident where one, with a history of aggression, hit another in the mouth despite staff attempts to intervene. The facility's documentation confirmed the occurrence of physical abuse, indicating a failure to protect residents from harm.
The facility failed to maintain proper hand hygiene and food temperature protocols during meal preparation and service, affecting all 50 residents. A cook was observed plating food without gloves and not performing hand hygiene after leaving the serving line. Food temperatures were not checked before plating, with some items below safe levels, requiring reheating. The Dietary Manager and District Manager acknowledged these lapses, which contravened the facility's policies.
The facility failed to maintain a pest-free environment, with flies present in the rooms of several residents, causing discomfort and complaints. The issue was exacerbated for residents using bedside commodes due to infrequent cleaning. Despite a pest control policy, minimal action was taken, and the Maintenance Director was unaware of the problem's extent.
The facility failed to properly administer medications, including giving expired and incorrect doses, and leaving medications unsupervised with residents. An RN was observed administering expired Multi-Vitamins and incorrect Lisinopril doses, and placing Lorazepam on a dirty surface. Medications were left unsupervised with residents, contrary to policy requiring supervision to ensure medications are taken.
Expired medications, including vaccines and insulin, were found in a facility's medication storage areas. A nurse was observed attempting to administer an expired Multi-Vitamin to a resident. The facility's policies on medication storage and administration were not followed, leading to the presence of expired drugs.
The facility did not meet the required 80 square feet per resident bed for nine residents, providing only 77.5 square feet in certain rooms. Despite this, no complaints were voiced by residents, and the affected individuals were documented as receiving a room waiver.
A resident with cognitive impairment and mobility issues experienced a lack of timely assistance with toileting, resulting in unsanitary conditions in their room. Despite the care plan requiring regular checks and assistance, the resident's bedside commode was not cleaned for extended periods, leading to distress and a violation of the facility's policy for a clean environment. The DON acknowledged the oversight, indicating a failure to uphold resident dignity and cleanliness.
A facility failed to provide a SNF ABN of Non-coverage to a resident with multiple diagnoses, including Osteomyelitis and Morbid Obesity. The resident's records showed a service discharge date, but no SNF ABN form was found in the EHR. The resident could not recall receiving the notice, and the administrator confirmed the absence of the form and acknowledged the lack of a policy for issuing SNF ABN forms.
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital. One resident's family did not receive a bed hold notice or discharge reason in writing, while another resident's Power of Attorney was informed by phone but not in writing. The facility's policies require written notifications, but documentation was lacking.
A facility failed to provide a resident's representative with written notification of a voluntary discharge and bed hold notice. The resident, who was alert and oriented, was transferred to a hospital for pain management and a UTI. Upon review, it was found that the resident's husband did not receive the required written documentation. The facility administrator acknowledged this oversight.
A resident with multiple health issues, including a nonhealing wound, did not receive timely follow-up on nurse practitioner recommendations for a vascular surgeon referral and an MRI. Despite physician's orders, the facility's electronic medical record lacked documentation of these actions. The resident reported inadequate repositioning care, and the receptionist was delayed in scheduling the MRI. The facility lacked a policy for scheduling consults.
A resident with a history of falls and severe cognitive impairment was transferred by a CNA without using a gait belt and with the wheelchair unlocked, contrary to the facility's safety policies. The resident's care plan required supervision and assistance due to high fall risk, but these protocols were not followed, resulting in a deficiency in maintaining a safe environment.
A resident with severe cognitive impairment and multiple diagnoses did not receive complete incontinent care. A CNA failed to have necessary supplies ready, did not use a gait belt properly, and neglected hand hygiene after wiping the resident's anal area. The CNA also did not clean the resident's front side, despite the incontinence brief being wet. The facility's policy emphasizes the importance of proper incontinence care to prevent skin breakdown.
The Facility failed to protect two residents from abuse, resulting in one resident feeling fearful and having trouble sleeping due to another resident's inappropriate sexual behaviors. Despite staff awareness, insufficient actions were taken to prevent further incidents.
The Facility failed to report allegations of abuse involving two residents. One resident alleged rape by a kitchen worker and had bruising, while another resident reported feeling extremely uncomfortable and scared after inappropriate sexual advances from a roommate. The Facility's Administrator did not report these incidents as required by their abuse policy.
The Facility failed to investigate an allegation of sexual abuse involving two residents. Despite one resident expressing discomfort and fear due to another resident's inappropriate sexual behavior, the Facility did not conduct an investigation as required by their abuse policy.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Follow Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy regarding the use of personal protective equipment (PPE) when providing care to two residents with indwelling urinary catheters. In the first instance, a resident with multiple diagnoses including rheumatoid arthritis, malnutrition, heart failure, and neurogenic bladder was observed with her catheter bag uncovered and lying on the floor. A Care Plan Coordinator/LPN entered the room, picked up the catheter bag, placed it in a cover, and attached it to the bed without donning gloves or a gown, despite clear signage indicating enhanced barrier precautions and readily available PPE at the door. The resident's care plan specifically required staff to wear gown and gloves during activities of daily living due to the risk of infection associated with the indwelling catheter. In the second instance, two CNAs provided catheter care to another resident with multiple diagnoses, including multiple myeloma and obstructive uropathy, who also required enhanced barrier precautions due to an indwelling catheter. During the observed care, neither CNA donned gowns, even though enhanced precautions signage and PPE were available at the room entrance. The resident's care plan and physician orders both specified the need for gown and glove use during high-contact care activities. The facility's EBP policy, dated 10/6/22, mandates the use of gown and gloves for high-contact care activities for residents with indwelling medical devices, but this protocol was not followed in these observed cases.
Failure to Provide Timely Toileting Care Compromising Resident Dignity
Penalty
Summary
The facility failed to provide timely care to residents dependent on staff for toileting hygiene, resulting in compromised dignity and comfort for multiple residents. One resident, who was cognitively intact and a bilateral lower extremity amputee with morbid obesity, reported waiting between 30 minutes to over an hour for call lights to be answered, leading to episodes of soiling herself and significant frustration. During direct observation, this resident was left on a bedpan for 29 minutes after requesting assistance, resulting in a pain level of 9 out of 10 and visible skin redness. The resident expressed concern for others who might not be able to advocate for themselves. Staff interviews confirmed that residents should be removed from bedpans within 5-10 minutes to avoid discomfort, but staffing shortages due to call-offs were noted as a contributing factor to delays. Other residents also reported excessive wait times for call light responses, ranging from 15 to 30 minutes, which made them feel uncared for and diminished their sense of dignity. Resident council meeting minutes from several months documented ongoing concerns about untimely call light responses. Facility policies on pain management and resident rights emphasized the importance of timely care to promote comfort and dignity, but these standards were not met as evidenced by the experiences and observations described.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
An LPN at the facility misappropriated narcotic pain medication prescribed to two residents who were both cognitively impaired and unable to advocate for themselves. The LPN was regularly assigned to these residents and documented the administration of hydrocodone-acetaminophen on the narcotic count sheets, but did not record these administrations on the residents' Medication Administration Records (MARs). The discrepancies were discovered when another nurse noticed unusual documentation and a rapid decrease in the pill count for one resident, despite the resident rarely requesting or receiving narcotic pain medication. Upon review, it was found that the LPN had signed out significantly more doses on the narcotic count sheets than were documented as administered on the MARs for both residents. The LPN admitted to taking the medication for personal use, stating she was in pain and did not have health insurance. She described a method of removing the medication from the cart, signing it out, and then pretending to administer it in the resident's room, where she would instead pocket the pills. The facility's audit confirmed that the LPN had taken a substantial number of pills over a period of several weeks. The residents involved had diagnoses including chronic pain, GERD, osteoarthritis, and cholecystitis, and were prescribed hydrocodone-acetaminophen on an as-needed basis. Both residents were described as not interviewable and did not have a history of frequent narcotic use. The misappropriation was only detected due to the vigilance of another nurse who noticed inconsistencies in the documentation and pill counts, leading to an internal investigation and subsequent admission by the LPN.
Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that progressive fall interventions were implemented and that staff were aware of these interventions for a resident identified as high risk for falls. The resident, who had diagnoses including diabetes mellitus, cerebral infarction, hypotension, dementia, and gait abnormalities, was severely cognitively impaired, used a wheelchair, and required partial assistance with walking. Despite being care planned as a fall risk and having a history of falls, interventions such as ensuring the resident wore grippy socks and the addition of a non-slip mat to the wheelchair were not consistently in place. On observation, the resident was found wearing regular socks without grips, and staff members interviewed were unaware of the requirement for grippy socks or the use of a non-slip mat. The resident experienced multiple falls, including one that resulted in a laceration, hematoma, and skin tears, requiring emergency room evaluation. Documentation showed that after each fall, interventions were updated in the care plan, but these were not effectively communicated or implemented by staff. Interviews with CNAs revealed a lack of awareness regarding the specific fall prevention measures, indicating a breakdown in communication and execution of the care plan interventions designed to prevent further accidents.
Breach of Resident Privacy and Dignity via Social Media Post
Penalty
Summary
The facility failed to respect a resident's rights regarding privacy and dignity, as evidenced by a social media post made by an LPN. The post, dated 9/10/2024, described a resident with identifiable characteristics, such as having five teeth and a receding hairline, without naming the resident or the facility. The post was intended as a joke among employees, but it was recognized by other staff members as referring to a specific resident, R2, who was alert and aware of the situation. R2 expressed that such a post would hurt his feelings and emphasized that no employee should post personal details about him on social media. The facility's administrator received an anonymous call about the post and forwarded the screenshots to human resources, who initially saw no issue since no names were mentioned. However, interviews with staff confirmed that the post was about R2, and comments from other employees on the post further identified the resident. The facility's Resident Rights Policy and Social Media Handbook prohibit disrespectful or discourteous comments about residents, highlighting a failure to uphold these standards. The incident underscores a breach of the resident's right to dignity and privacy, as outlined in the facility's policies.
Failure to Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to implement progressive interventions for a resident identified as high risk for falls, leading to multiple incidents without adequate preventive measures. The resident, who has a complex medical history including encephalopathy, COPD, hemiplegia, and dementia, experienced several falls over a short period. Despite these incidents, the facility did not document or implement new interventions to prevent future falls, as required by their fall prevention policy. The resident's care plan and incident reports repeatedly noted the same interventions following each fall, without any new strategies being introduced. This lack of progressive intervention was acknowledged by the facility's staff, including the Assistant Director of Nursing, Care Plan Coordinator, and Director of Nursing, who admitted that the same interventions were used multiple times without modification. The facility's policy mandates that each fall should be followed by a new intervention, which was not adhered to in this case. Interviews with facility staff revealed that the interdisciplinary team was supposed to meet to discuss and implement new interventions after each fall, but this process was not effectively carried out. The Care Plan Coordinator admitted to an error in not updating the care plan with new interventions, and the Director of Nursing, who was new to the position, confirmed that the care plan should reflect each fall with appropriate interventions. This oversight resulted in a failure to provide adequate supervision and preventive measures for the resident, as required by the facility's fall policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents. Resident 1, who was moderately cognitively impaired and required assistance with mobility, had a history of verbal aggression and physical altercations with other residents. On the day of the incident, Resident 1 was observed by the Environmental Services Director swatting at Resident 2, who was severely cognitively impaired but independent with ambulation. Despite attempts to intervene, Resident 1 hit Resident 2 in the mouth. The facility's documentation, including the initial and final reports to the Illinois Department of Public Health, confirmed the occurrence of physical abuse. The facility's abuse policy, which prohibits abuse and mistreatment of residents, was not effectively implemented in this case. The incident was substantiated as physical abuse, highlighting a failure to protect residents from harm and ensure their safety within the facility.
Failure in Hand Hygiene and Food Temperature Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene and food temperature protocols during meal preparation and service, potentially affecting all 50 residents. On the observed date, a cook was seen plating food without wearing gloves and without performing hand hygiene after leaving and returning to the serving line multiple times. The cook also handled gluten-free bread with bare hands before being instructed to use tongs. Additionally, the cook did not check food temperatures before plating, which is against the facility's policy. The temperatures of various food items, including mechanically altered and pureed foods, were found to be below the required safe levels, necessitating reheating. The facility's policies require that food temperatures be checked at multiple stages, including before plating, and that proper hand hygiene and utensil use be maintained to prevent contamination. However, the kitchen staff did not follow these protocols, as evidenced by the lack of documented temperature checks at the time of service and the observed lapses in hand hygiene. The Dietary Manager and District Manager acknowledged these failures, noting that the cook should have checked temperatures before plating and performed hand hygiene as necessary.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of flies in the rooms of six residents. Observations and interviews revealed that residents were experiencing significant discomfort due to the flies, with some residents having fly swatters in their rooms as a makeshift solution. Residents reported that the issue had persisted for several months, and complaints had been made without any effective action taken by the facility. The presence of flies was particularly problematic for residents using bedside commodes, as the lack of frequent cleaning exacerbated the situation. The Director of Nursing and the Maintenance Director were both made aware of the issue, with the Maintenance Director initially unaware of the extent of the problem. The facility's pest control policy, dated 2017, mandates an ongoing pest control program, yet the last recorded pest control service was on 7/17/2024. Despite this, the Maintenance Director claimed that there were not many flies and that minimal action had been taken, such as placing sticky fly traps in hallways but not in residents' rooms.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to properly administer medications to residents, as evidenced by several incidents involving incorrect medication administration and handling. A registered nurse (RN) was observed administering expired Multi-Vitamin tablets to a resident and incorrectly dosing Lisinopril, contrary to the physician's order. The nurse acknowledged the error and intended to verify and correct the order. Additionally, the nurse was seen placing a Lorazepam tablet on a dirty surface before administering it to another resident, which is against proper medication handling protocols. In another instance, a resident was left with a cup of medications on their bedside table while being attended to by staff. The medication administration record indicated that some medications were not signed off as administered, and the nurse admitted to not completing the administration of all prescribed medications. Similarly, another resident was found with a bottle of Cinacalcet tablets in their wash basin and a cup of medications on their bedside table. The nurse admitted to leaving the medications for the resident to take on their own, which is against the facility's policy of ensuring residents take their medications under supervision. The facility's medication administration policy requires that medications be administered safely and appropriately, with nurses remaining with residents to ensure they swallow their medications. The policy also mandates that expired medications be removed from stock and disposed of properly. The incidents observed indicate a failure to adhere to these policies, resulting in improper medication administration and handling, which could potentially compromise resident safety.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to properly manage and store medications, leading to the presence of expired drugs in the medication room refrigerator, medication shelf, and medication cart. During an inspection, several expired medications were found, including a COVID-19 vaccine, insulin pens, and various vials of insulin and Daptomycin. Additionally, expired Aspirin bottles were discovered in the medication storage room. A Licensed Practical Nurse confirmed the expiration of these medications, and the facility's Administrator stated that the Director of Nursing and Assistant Director of Nursing are responsible for monthly checks of the medication storage areas. Furthermore, a Registered Nurse was observed administering an expired Multi-Vitamin to a resident, which was only discovered upon examination of the bottle. The nurse then attempted to find a non-expired bottle on another medication cart, but it was also expired. The facility's policies on medication storage and administration emphasize the importance of checking expiration dates and ensuring medications are stored and administered correctly. However, these policies were not adhered to, resulting in the use of expired medications.
Deficiency in Room Size Compliance
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident bed for nine residents in a sample of 41. During the survey, it was observed that rooms on the 100 hall, which were Medicare and Medicaid certified, provided only 77.5 square feet per resident bed. The administrator confirmed that there had been no changes in the measurements and accuracy of the facility's waivered resident room numbers and certifications. Despite the deficiency, no residents vocalized concerns or complaints about the room size during observations and a resident group meeting. The facility documented that the affected residents were all receiving a room waiver.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility failed to maintain a dignified and respectful environment for a resident, identified as R11, by not providing timely removal of urine and feces from the resident's bedside commode. R11, who was admitted with diagnoses including anxiety, major depressive disorders, and a fracture of the spine, was documented as moderately cognitively impaired and required partial assistance for toileting. Despite these needs, the facility did not adhere to the care plan that required rounding every two hours to assist with toileting and ensure the resident was clean and dry. During the investigation, it was observed that R11's commode was not cleaned for extended periods, leading to unsanitary conditions with stool and urine present, attracting flies. R11 reported waiting four hours for the commode to be emptied and expressed distress over the situation. Observations confirmed that the commode remained uncleaned over multiple days, and the floor was smeared with stool. The Director of Nursing acknowledged the issue and stated that the commode should have been cleaned after each use, highlighting a failure to comply with the facility's Resident Rights Policy to provide a clean and homelike environment.
Failure to Provide SNF ABN of Non-Coverage
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) of Non-coverage to a resident, identified as R6, who was reviewed for Beneficiary Notice. R6 was admitted to the facility with diagnoses including Osteomyelitis of Vertebra, Morbid Obesity, Weakness, and Difficulty Walking. The facility's records indicated a service discharge date for R6, but there was no SNF ABN form associated with this date in R6's Electronic Health Record (EHR). During an interview, R6 could not recall receiving a SNF ABN regarding the discharge. The facility administrator confirmed the absence of the SNF ABN form in both R6's EHR and the facility's Notice of Medicare Non-Coverage (NOMNC) folder, acknowledging the error and the lack of a current policy for issuing SNF ABN forms.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding an involuntary discharge and the opportunity for appeal. In the case of one resident, identified as R51, there was no documentation that the resident's husband received written notification of the discharge to the hospital or a bed hold notice. The resident was initially admitted to the facility and later requested to be sent back to the hospital due to pain, where they were admitted for a urinary tract infection and pain management. The facility administrator acknowledged that the family should have been provided with the necessary written notifications. Additionally, another resident, identified as R9, was transferred to the hospital following a fall. The resident's Power of Attorney was notified by phone but did not receive any written documentation regarding the transfer. The facility's bed hold policy, last reviewed in September 2023, requires that written information be provided to the resident or their representative upon transfer. However, there was no documentation that this was done for R9. The facility's discharge policy also lacked documentation on the need to provide written notification to residents' representatives upon transfers.
Failure to Provide Written Discharge and Bed Hold Notice
Penalty
Summary
The facility failed to notify a resident's representative in writing regarding the voluntary discharge and bed hold notice. The resident, who was alert and oriented, was admitted to the facility and later requested to be sent back to the hospital due to severe pain. The resident was transferred to the hospital via EMS, where they were admitted for a urinary tract infection and pain management. Upon review, it was found that there was no documentation indicating that the resident's husband received written notification of the discharge reason or a bed hold notice. The facility administrator acknowledged that the family should have been provided with this information in writing.
Failure to Follow NP Recommendations for Resident Care
Penalty
Summary
The facility failed to follow the nurse practitioner's recommendations in a timely manner for a resident with multiple diagnoses, including an unspecified open wound on the left lower leg, Type II Diabetes Mellitus, paraplegia, and polyneuropathy. The resident's care plan indicated a risk for skin complications due to immobility. Physician's orders were documented for a referral to a vascular surgeon and an MRI of the left knee to address a nonhealing wound. However, the electronic medical record showed no documentation of a referral to a vascular surgeon or a scheduled MRI appointment. The resident reported that staff did not regularly turn or reposition him every two hours, and he had not refused such care. He confirmed that he had not undergone an MRI or consulted with a vascular surgeon, despite the nurse practitioner's recommendations. The receptionist responsible for scheduling appointments stated that she had contacted the hospital to arrange an MRI but was waiting for a callback. The facility administrator expected nurses to enter orders, obtain consent, and notify the scheduler for consults, but there was no policy for scheduling consults, only for medication orders.
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R5, during transfers, which is a deficiency in maintaining a safe environment free from accident hazards. R5, who has a history of multiple falls and is considered a high fall risk, was observed being transferred by a Certified Nursing Assistant (CNA) without the use of a gait belt and with the wheelchair left unlocked. This action is contrary to the facility's Gait Belt Policy, which requires the use of a gait belt for weight-bearing residents needing hands-on assistance during transfers. R5's medical history includes severe cognitive impairment, dementia, traumatic brain injury, and a history of falls, among other conditions. The resident's care plan highlights the need for supervision and assistance with activities of daily living, including transfers. Despite these documented needs and the resident's high fall risk status, the CNA did not follow the prescribed safety procedures during the transfer, which included securing the wheelchair and using a gait belt. The facility's policies on fall prevention and gait belt usage emphasize the importance of maintaining resident safety through proper transfer techniques and the use of assistive devices. The Director of Nursing confirmed the expectation that staff should use gait belts and lock wheelchairs during transfers to ensure resident safety. However, these protocols were not adhered to in the case of R5, leading to a deficiency in the facility's safety procedures.
Incomplete Incontinent Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide complete incontinent care for a resident with severe cognitive impairment and multiple diagnoses, including dementia, traumatic brain injury, and osteoarthritis. The resident, who is always incontinent of both bowel and bladder, was observed being assisted by a CNA to use the restroom. The CNA did not have the necessary supplies ready and had to leave the resident unattended to gather them. During the care process, the CNA did not use a gait belt properly and failed to perform hand hygiene after wiping the resident's anal area before applying Peri-Guard cream with the same soiled gloves. Additionally, the CNA did not clean or wipe the resident's front side, despite acknowledging that the incontinence brief was wet. The Director of Nursing later stated that staff are expected to provide complete incontinent care, including having necessary supplies available and performing hand hygiene. The facility's Incontinence Care Policy emphasizes the importance of keeping residents dry, comfortable, and odor-free to prevent skin breakdown, and specifies that cleansing should be done from front to back.
Failure to Protect Residents from Abuse
Penalty
Summary
The Facility failed to ensure an environment free from abuse for two residents, R1 and R2. R1, who has diagnoses including type 2 diabetes, COPD, congestive heart failure, anxiety, depression, osteoarthritis, and muscle weakness, was admitted to the facility and was documented as being at risk for abuse and neglect. R2, who has diagnoses including encephalopathy, multiple sclerosis, bipolar disorder, schizoaffective disorder, and major depressive disorder, was admitted to the facility and was documented as being moderately cognitively impaired. Despite R2's cognitive impairments and inappropriate sexual behaviors, R2's care plan did not address the risk for abuse or identified sexual behaviors. R1 and R2 were placed in the same room, which led to multiple incidents where R2 made sexual advances towards R1, including crawling into R1's bed, making sexual comments, and asking R1 to help with masturbation. These incidents caused R1 to feel fearful and have trouble sleeping. Staff members, including an LPN and a CNA, were aware of R2's inappropriate behaviors but did not take sufficient action to prevent further incidents. The LPN documented R2's behaviors and attempted to redirect R2, but the inappropriate actions continued. The CNA also witnessed R2's inappropriate behavior and separated the residents but did not ensure that R2 was moved to a different room. The facility's abuse policy affirms the right of residents to be free from abuse and requires the facility to protect residents from mistreatment by anyone, including other residents. However, the facility failed to follow this policy, resulting in R1 feeling scared and uncomfortable due to R2's actions.
Failure to Report Allegations of Abuse
Penalty
Summary
The Facility failed to report allegations of abuse involving two residents. Resident R2, who has multiple diagnoses including encephalopathy and schizoaffective disorder, was found to have made hypersexual statements and had bruising on her body. A Sexual Assault Nurse Examiner (SANE) from a local hospital reported that R2 tested positive for pregnancy and had bruising, and R2 alleged that a kitchen worker had raped her. Despite this, the Facility's Administrator did not report the alleged rape because Public Health was already present in the building, and she was unsure if it was necessary to report it. Additionally, Resident R1, who has diagnoses including type 2 diabetes and chronic obstructive pulmonary disease, reported feeling extremely uncomfortable and scared after R2 crawled into her bed, made sexual comments, and asked for help with masturbation. Staff members, including a CNA and an LPN, were aware of the incident and reported it to the Administrator. However, the Administrator did not report the incident because R1 stated she did not feel violated or harassed. The Facility's abuse policy mandates the immediate reporting of any allegations of abuse to the Illinois Department of Public Health, but this protocol was not followed in the cases of R1 and R2. The Facility's failure to report these incidents constitutes a deficiency in adhering to their own abuse prevention and reporting policies.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The Facility failed to investigate an allegation of sexual abuse involving two residents. Resident 1 (R1) was admitted with multiple diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and anxiety, and was documented as being at risk for abuse and neglect. Resident 2 (R2) was admitted with diagnoses including encephalopathy, multiple sclerosis, and schizoaffective disorder, and was moderately cognitively impaired. On the night of the incident, R2 was found in R1's bed making sexual comments and asking for help with masturbation. Despite R1 expressing discomfort and fear, the Facility did not conduct an investigation into the incident as required by their abuse policy. Staff interviews and progress notes revealed that R2 had a history of making inappropriate sexual comments and actions towards R1. R1 reported feeling scared and uncomfortable due to R2's behavior. The Facility's Administrator stated that no investigation was conducted because R1 did not feel violated or harassed. However, the Facility's abuse policy mandates that all incidents or allegations of abuse must be investigated, regardless of the resident's immediate feelings. This failure to investigate the incident constitutes a deficiency in the Facility's adherence to its abuse prevention and response protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 276 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mascoutah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Bella Of Mascoutah | 0.6 mi | ★★★★★ | 15 | 0 |
| Clinton Manor Living Center | 6.6 mi | ★★★★★ | 0 | 0 |
| Cedar Ridge Health & Rehab Ctr | 7.5 mi | ★★★★★ | 8 | 0 |
| La Bella Of Freeburg | 7.5 mi | ★★★★★ | 4 | 0 |
| Evercare Of Lebanon | 8.1 mi | ★★★★★ | 6 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Nexus At Mascoutah.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.