Cass County Senior Living & Rehabilitation LLC

Inspectors wroteBased on interview and record review the facility failed to ensure residents are without significant medication errors for one (R1) of three reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to secure a treatment orders promptly, and delayed the implementation of new interventions once skin breakdown was discovered to prevent worsening of a pressure wound for one of two residents (R23) reviewed for pressure ulcers in the sample of 24. These failures resulted in R23's facility acquired pressure wound worsening to a stage three.

Inspectors wroteBased on record review and interviews the facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 26 residents residing within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the food items opened in the kitchen's dry storage, refrigerator and freezer were dated and labeled. These failures have the potential to affect all 26 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician in a timely manner following a significant change in condition (fall with head injury) while receiving an anticoagulant medication Eliquis, for one (R27) of one resident reviewed for physician notification out of a sample list of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an appropriate diagnosis and target behaviors to warrant the use of anti-psychotic medications for two of six residents (R1 and R29) reviewed for anti-psychotic medication use with the diagnosis of Dementia in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised to reflect current interventions implemented for mobility and fall prevention for one (R26) of one resident reviewed for care plan revision in a sample of 24 residents.

Inspectors wroteBased on interview and record review the facility failed to provide ordered medication for one of one resident (R17) reviewed for quality of care in the sample of 24.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were free from accident hazards and received adequate supervision and assistive devices to prevent accidents for one (R27) of one resident reviewed for accidents in the sample list of 24. This failure resulted in (R27), a resident prescribed a blood thinner (Eliquis), falling from a wheelchair and striking his head on the floor, sustaining a large, painful discolored area to the back of the head.

Inspectors wroteBased on interview and record review the facility failed to replace oxygen tubing and humidifier bottle for one two residents (R1) reviewed for oxygen in the sample of 24.

Inspectors wroteBased on interview, observation, and record review, the facility failed to apply a gown prior to providing high-contact care for a resident with a wound for one of one resident (R6) reviewed for EBP (Enhanced Barrier Precautions) in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with hot water in their personal showers and sinks for two of three residents (R2, R3) reviewed for adequate hot water temperatures in the sample of four.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a diagnosis of hemiplegia, was transferred safely to prevent skin tear injury to their affected arm, for one of three residents (R1) reviewed for injury in the sample of four.

Inspectors wroteBased on record review and interview the facility failed to implement a surveillance plan for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks among residents and staff. These failures have the potential to affect all 27 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to designate a qualified infection preventionist to implement the facility's infection prevention and control programs. This failure has the potential to affect all 27 residents residing within the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a plan of care to address a resident's UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTIs in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers in the resident's bathrooms were free of a brown/black furry textured substance, water was available in one shower room, faucets were in good working order, cracked tile in the shower rooms was repaired, unconnected piping wasn't exposed, and functioning ventilation fans in resident rooms. This failure has the potential to affect all 26 residents who reside in the facility. Findings Include:The Facility's current resident census sheet dated 7/16/2025, documents 26 residents reside in the facility. The Facility's Safety and Supervision of Residents policy dated 11/14/2024 documents, Policy Statement, our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide eight consecutive hours of a Registered Nurse, daily. This failure has the potential to affect all 26 residents who reside in the facility. Findings Include:The Facility's current resident census sheet dated 7/16/2025, documents 26 residents reside in the facility. The Facility's Staffing policy (not dated) documents, Policy Statement, our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The Facility's staffing sheets dated 6/16/2025-7/16/2025 document all days with no Registered Nurse for eight consecutive hours, 6/28, 6/29,7/3, 7/3, 7/5, 7/6, 7/10, 7/12, 7/16. [...]

Inspectors wroteBased on interview and record review the facility failed to use a gait belt, or a two person assist for a transfer for one resident (R3) of two residents reviewed for falls in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two residents (R19 and R24) of two residents reviewed for EBP in the sample of 20.

Inspectors wroteBased on observation, interview and record review the Facility failed to store and label open food items in the Facility refrigerator and freezer. This failure has the potential to affect all 28 Residents residing in the Facility.