Health inspection·July 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include:1. R1's Face Sheet, with original admission date of 01/15/18, documented R1 has diagnoses of but not limited to multiple sclerosis, schizoaffective disorder, and bipolar disorder. R1's Minimum Data Set (MDS), dated [DATE], documented R1 is moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 10 out of 15, she is dependent on staff for most of her activities of daily living (ADL), and she is always incontinent of bowel and bladder.On 07/22/25 at 9:55 AM, R1 said it can sometimes take the Certified Nursing Assistants (CNA) a little while to answer her call light.2. R3's Face Sheet, admission date of 06/20/25, documented R3 has diagnoses of but not limited to congenital subaortic stenosis, type II diabetes mellitus, schizophrenia, and hypertension (HTN). R3's MDS, dated [DATE], documented R3 is cognitively intact with a BIMS of 13 out of 15 and she requires assistance with her ADLs.On 07/21/25 at 10:00 AM, R3 said she had an incident that happened last Monday (07/14/25) where she was up in her wheelchair (w/c) at 2:00 PM and she put her call light on to get help going to the bathroom. R3 said no one came in to help her until 4:00 PM. She said later that same night at about 9:00 PM she put her call light on to use the bedpan and no one came until 10:00 PM. She said she has had two accidents due to having to wait on someone to answer her call light. R3 said her very first night here and then again about two or three weeks ago she had an accident, and it makes her uncomfortable. She said is worried she is going to get sores and stuff if she is wet. R3 said her first night here she had to wait five and a half hours for any kind of help to use the bathroom. 3. R4's Face Sheet, print date of 07/23/25, documented R4 has diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), sepsis, type II diabetes mellitus, and chronic atrial fibrillation. R4's MDS, dated [DATE], documented R4 is cognitively intact with a BIMS of 15 out of 15, requires assistance with some of her ADLs and is occasionally incontinent of bladder and frequently incontinent of bowel. On 07/23/25 at 10:17 AM, R4 said it can take the CNAs (Certified Nurses Assistants) sometimes a couple of hours to answer the call light. Sometimes when she has her call light on, they will peak in the room and then just walk away. R4 said she has had accidents having to wait on someone to answer the call light. She said it ticks her off when that happens and there are times her roommate must yell for help before they come to check and see what she needs.4. R6's Face Sheet, print date of 07/23/25, documented R6 has diagnoses of but not limited to COPD, HTN, emphysema, and atrial fibrillation. R6's MDS, dated [DATE], documented R6 is cognitively intact with a BIMS of 14 out of 15 and requires assistance with some of her ADLs. On 07/23/25 at 10:40 AM, R6 said it can be slow when it comes to answering the call lights. She said sometimes it can be as long as an hour to an hour and a half before they come. She said the second and night shift seem to be the worst.The facility's Resident Council Meeting Minutes, dated 05/01/25, Page 1 of 3 145785 145785 07/24/2025 Nexus at Mascoutah 901 North Tenth Street Mascoutah, IL 62258

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented Resident Council Nursing Concerns: Call lights not being answered in a timely manner.The facility's Resident Council Meeting Minutes, dated 06/05/25, documented Resident Council Unresolved Concerns: Call lights not being answered in a timely manner.The facility's Resident Council Meeting Minutes, dated 07/03/25, documented Resident Council Nursing Concerns: Call lights not being answered in a timely manner.The facility's call light response audit tool, dated 07/19/25, documented a call light on the 100 hallway was on at 8:56 AM and it was turned off at 9:15 AM. There was a 19-minute response time.On 07/22/25 at 10:30 AM, V4, Certified Nursing Assistant (CNA) said it is hard for her to get her tasks done and call lights answered timely.On 07/22/25 at 10:35 AM, V5, CNA said doesn't feels like she has time to get all her daily tasks done and she doesn't feel like she is able to answer the resident's call lights in a timely manner.On 07/23/25 at 12:30 PM, V1, Administrator said when it comes to the call lights the Assistant Director of Nursing, V8, has been doing a call light audit on the second and night shift and the response time has been 5 minutes or less recently.On 07/23/25 at 3:20 PM, V1 said call lights should be answered as soon as possible, within at least 5 minutes would be ideal.The facility's Call Light Response, revision date of 09/2024, documented GENERAL: To provide the staff with guidance on responding to resident's request and needs. It also documented Protocol: 6. Answer the patient or resident's call as soon as possible. 145785 Page 2 of 3 145785 07/24/2025 Nexus at Mascoutah 901 North Tenth Street Mascoutah, IL 62258

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. Findings include:On 07/21/25 at 10:15 AM, in the shower room/bathroom on the 100-hallway, the clean linen cart was sitting next to the commode in the shower room and the clean linen cart did not have the front cover pulled down to cover all the clean linen and thus the clean linen was exposed to different contaminates. In the shower room there was also dirty linen barrels as well as the clean linen.On 07/22/25 at 10:40 AM, in the women's shower room on the 200-hallway, the clean linen cart was sitting up against the wall with the cover thrown up over the top of the cart and all the linen on the cart was exposed. There were two barrels containing dirty linen on wheels sitting about three feet away from the clean linen.On 07/22/25 at 10:45 AM, in the men's shower room on the 200-hallway there was a clean linen cart sitting up against the wall with the cover flipped up on the top of the cart exposing all the clean linen to different kinds of contaminates. On 07/23/25 at 10:17 AM, R4 state the linen cart that is kept in the shower room always has the cover up on it.On 07/23/25 at 10:40 AM, R6 stated the clean linen cart in the shower room is always left open and she hasn't ever seen it covered.On 07/23/25 at 12:45 PM, V5, Certified Nursing Assistant (CNA) said the cover has to be down on the clean linen cart at all times.On 07/23/25 at 12:30 PM, V1, Administrator stated when it comes to the clean linen carts, she expects for the staff to make sure the front is covered and pulled down and it has to be at least a door width away from the dirty linen containers per what the policy says.The facility's policy Handling Clean Linen, last updated July 2019, documented Policy: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Definitions: Hygienically clean means rendered free of vegetative pathogens through disinfection during the laundering process. Linen including sheets, blankets, pillows, towels, washcloths, and similar items from departments such as nursing, dietary, rehabilitative services, beauty shops, and environmental services. Contaminated Linen is linen that has been soiled with blood or other potentially infectious materials. It further documented Policy Explanation and Compliance Guidelines: 2. Linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. It also documented 5. Guidelines for the storage of clean linen include, but are not limited to, the following: a. Clean linen shall be delivered to resident care units on covered linen carts with covers down. Nothing shall be kept on top of linen carts. Only rolls of bags used for linen transport may be kept on the carts, in the designated pockets only. b. Clean linen shall be kept separate from soiled linen. When clean linen carts are in use (i.e. in the hallway), keep at least one door length away from soiled linen collection containers.The facility's census sheet, dated 7/21/25, documented there were 51 residents in the facility. Residents Affected - Many 145785 Page 3 of 3