Health inspection·September 10, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, cerebral infarction, and unspecified dementia with agitation. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired, required partial assistance with bed mobility, was dependent with transfer, and ambulated via wheelchair. R1's Undated Care Plan documents R1 has potential to be verbally aggressive to other residents and staff related to poor impulse control. The Care Plan update on 11/26/22 documents, Pulled female resident's hair in dining room. The Care Plan update on 8/26/24 documents, Hit female resident in the mouth. R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including muscle weakness, major depressive disorder, and unspecified dementia without behavioral disturbance. R2's MDS dated [DATE] documented R2 was severely cognitively impaired, but was independent with ambulation and transfer. R2's Undated Care Plan documents R2 is at risk for abuse and neglect related to wandering and dementia. The Care Plan update on 8/26/24 documents, Physical abuse by another resident. The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 8/26/24 documents alleged abuse involving R1, perpetrator, and R2. The Report documents, On Monday 8/26/24 at approximately 9:10 am, (V3, Environmental Services Director) observed (R2) in the dining room near (R1). At first (R1) was swatting at (R2) in attempt to shoo her away. Before (V3) could get to (R2) to help redirect her, (R1) swatted and hit (R2) in the mouth. R2's Progress Note dated 8/26/24 at 9:10 am documents, On Monday 8/26/24 at approximately 9:10am, (V3, Environmental Services Director) observed (R2) in the dining room near resident (R1) At first, he was swatting at (R2) in attempt to shoo her away. Before (V3) could get to (R2) to help redirect her, (R1) swatted and hit (R2) in the mouth. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145785 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Nexus at Mascoutah 901 North Tenth Street Mascoutah, IL 62258 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)