Cass County Senior Living & Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Cass County Senior Living & Rehabilitation LLC, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 3, 2026

  Based 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.Findings include:The Prevention of Pressure Ulcers/Injuries policy dated 07/2017 documents The purpose of this procedure is to provide information regarding the identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Risk Assessment 4. […]

• No harm, potential for more than minimal, widespreadF727Mar 3, 2026

  Based 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.Findings include: The facility's Nurse Schedule, January 1st through February 28th, 2026, documents the facility did not have the services of a registered nurse at least eight hours a day on 01/31/26, 2/14/26, 2/15/26, and 2/28/26.On 3/1/26 at 11:24 AM V2/RN/Prior Director of Nursing verified the provided nurse schedules were accurate and on 1/31/26, 2/14/26, 2/15/26, and 2/28/26 no RN worked those days. V2/DON stated, I am responsible for scheduling the nurses. We have a hard time finding any RNs to work. That's why we cannot provide RN coverage eight hours per day. […]

• No harm, potential for more than minimal, widespreadF812Mar 3, 2026

  Based 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.Findings include: The facility's Food Storage (Dry, Refrigerated, and Frozen) Policy, dated 3/31/25, documents Guidelines: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. a. All food items will be labeled. […]

• No harm, potential for more than minimal, widespreadF880Sep 21, 2025

  Based 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.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Surveillance for Infections policy dated 09/2027 documents, The facility will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. a. […]

• No harm, potential for more than minimal, widespreadF882Sep 21, 2025

  Based 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.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Infection Preventionist Job Description dated 10/12/20 documents, The Infection Preventionist is responsible for the effective direction, management, and operation of the infection prevention program. […]