Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Cass County Senior Living & Rehabilitation Llc during CMS and state inspections, most recent first.
Significant warfarin medication error: A resident with HTN, dementia, parkinsonism, BPH, and cerebrovascular disease had a critically high INR, yet the MAR showed warfarin 2 mg daily was still administered for multiple days after a verbal order was reportedly given to hold the medication and repeat PT/INR. The facility had no documented order or lab result for the repeat test, and the MD later confirmed the anticoagulant should not have been given.
A resident with malnutrition, PVD, osteoporosis, fragile skin, and limited mobility developed a new buttock/coccyx wound after being bedbound with Influenza A. Staff first noted an open area and MASD, but treatment orders were delayed for several days and the care plan was not updated with new interventions until the wound doctor later evaluated the resident and classified the wound as a stage III pressure ulcer.
The facility failed to ensure RN coverage for at least 8 hours per day. Review of the nurse schedule showed multiple days when no RN worked, and the former DON confirmed the schedule was accurate and stated the facility had difficulty finding RNs to work. The CMS 671 documented 26 residents in the facility.
Food items in kitchen dry storage, the refrigerator, and the freezer were found opened but undated and unlabeled. Surveyors observed egg rolls, frozen dinner rolls, a nutritional supplement, and opened spice containers without required open dates, and the cook and dietary manager verified the items should have been labeled. The facility's CMS 671 documented 26 residents.
A resident on Eliquis fell backward from a wheelchair while being dressed by CNAs and struck the back of his head, with an abrasion noted on assessment. The nurse documented normal VS and neuro checks, but the physician was not notified by phone at the time of the incident and was instead faxed the next day; the physician and DON both stated this type of head injury on a blood thinner should have been reported by phone.
The facility failed to document appropriate diagnoses and target behaviors to support antipsychotic use for two residents with dementia. One resident receiving Seroquel had no care plan documentation of targeted behaviors or non-pharmacological interventions, and the DON stated dementia alone was not an appropriate diagnosis for the medication. Another resident receiving quetiapine for vascular dementia with behaviors was observed calm and pleasant, while staff reported only sexual comments to staff that were easily redirected, with limited behavior documentation in the care plan.
Care Plan Not Updated for Mobility and Fall Interventions: A resident’s comprehensive care plan was not revised to reflect current mobility and fall-prevention interventions. The resident was observed with a fall mat by the bed and a high-back wheelchair with a foot board and stability cushion, but the care plan did not include these interventions or a scoop mattress. The care plan also referenced a non-slip mat in the wheelchair, yet none was observed. An OTA stated staff were repositioning the resident in the wheelchair because she frequently placed her legs over the side and slid forward, and the DON confirmed the interventions were not included in the care plan.
Failure to provide ordered Testosterone Gel: A resident with osteoporosis, fatigue, muscle weakness, and intellectual disability had a discharge med list and subsequent MD order for Testosterone Transdermal Gel, two pumps daily to the shoulders, but the med was not administered for weeks. Nursing notes show repeated calls to the PCP office and pharmacy because the script was not signed and the pharmacy would not fill it until signed authorization was received. The resident did not receive the medication until the pharmacy finally filled the order, and the resident was later observed sitting in a recliner, covered with a blanket, and unable to answer questions appropriately.
A resident with severe cognitive impairment, high fall risk, and Eliquis use fell backward from a wheelchair during morning care when CNAs lifted his legs to look underneath him for a shirt. He struck his head on the floor and developed a painful discolored area on the back of his head. The physician was notified by fax instead of phone, and the fall investigation was not included in the medical record.
Failure to replace oxygen tubing and the humidifier bottle was identified for a resident who required oxygen and had diagnoses including acute respiratory failure, COPD, and vascular dementia. The resident was observed wearing oxygen with a humidifier bottle dated outside the expected change interval, and an LPN, RN, and DON confirmed that oxygen equipment and humidifier bottles are handled on a 7-day change schedule.
An LPN failed to wear a gown while providing wound care to a resident on EBP with an open coccyx pressure sore. Facility policy required gowns and gloves for high-contact care, including wound care, for residents with chronic wounds, and the LPN later confirmed the gown was omitted and should have been worn.
Residents did not have hot water in their private showers or sinks. Two residents said their bathroom water was cold and that they could not use their room showers as preferred, with one using a cold washcloth at the sink instead. CNAs reported the hot water problem had affected multiple halls for months, and the maintenance director confirmed the facility’s water heater was intermittently working. Surveyor checks found shower room water at 90 F and both residents’ bathroom shower and sink water at 65 F.
Unsafe Transfer Resulted in Skin Tear to Resident’s Affected Arm: A resident with hemiplegia, reduced mobility, and muscle weakness was assisted by a CNA and an LPN during a commode-to-chair transfer, but the resident’s weaker arm slipped under the commode armrest and was injured as the resident was lifted. The resident had documented skin tears to the affected arm and required staff assistance with transfers and positioning of the arm to prevent injury.
The facility did not maintain required infection surveillance and tracking logs for residents and staff, relying instead on incomplete antibiotic order reports that lacked key information such as resident identifiers, infection onset dates, and pathogen details. The DON confirmed that infection control logs had not been completed for several months, resulting in the absence of a functional system to monitor infections and outbreaks.
The facility did not designate a qualified infection preventionist to oversee its infection prevention and control program. The DON was assigned this responsibility but had not completed the required infection preventionist training, and regional oversight was infrequent. The facility's staffing plan did not include an infection preventionist despite the current census.
A resident with a confirmed UTI, as indicated by a positive urine culture and an order for antibiotics, did not have a care plan developed or implemented to address the infection. The facility's policy requires care plans to be updated with changes in condition, but this was not done, as verified by the administrator.
Surveyors identified widespread environmental hazards, including mold-like substances in showers, broken tiles, leaking faucets, exposed piping, and non-functioning ventilation fans in resident areas. Facility leadership was aware of these issues but had not taken sufficient action to address them, potentially affecting all residents.
The facility did not ensure an RN was present for eight consecutive hours each day, as staffing records showed multiple days without the required RN coverage. The DON, who is the only RN, confirmed she was unable to fulfill all required RN hours due to her multiple responsibilities.
A resident with severe mental and physical impairments was transferred by a single CNA without a gait belt, contrary to facility policy requiring a two-person assist. The resident, who has a high fall risk, became weak and was lowered to the floor without injury. The incident highlighted a failure to follow established protocols for safe transfers.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with an indwelling urinary catheter and another with a stage two pressure ulcer. Neither resident had EBP signs or PPE available, and staff were unaware of EBP requirements. This indicates a lack of communication and training regarding infection prevention measures.
Significant Warfarin Medication Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors involving warfarin. The resident was admitted with diagnoses including hypertension, osteoarthritis, dementia, parkinsonism, benign prostatic hyperplasia, and cerebrovascular disease. Laboratory results documented a PT of 47.8 and an INR of 5.1, described as critically high. The facility’s Telephone Orders Policy stated verbal telephone orders may only be received by licensed personnel and must be recorded in the resident’s medical record. A nurses note documented that the facility received a faxed request for PT/INR results for the resident, but no lab had been drawn on the requested date and no order was found. The medical director stated she had given a verbal order to hold warfarin and recheck PT/INR based on an INR of 5.1, but the facility did not have those results or any order in the record. The resident’s MAR showed warfarin 2 mg daily was administered from 2/1/26 through 2/11/26, and the medical director later confirmed the resident received warfarin during that period and that the repeat PT/INR was not performed. The administrator also confirmed the resident received warfarin 2 mg daily during that time and that the medication should not have been given.
Delayed treatment and care plan response for a newly identified pressure wound
Penalty
Summary
A resident with mild protein-calorie malnutrition, peripheral vascular disease, osteoporosis, fragile skin, weakness, and limited ROM was found to have new skin breakdown on the right buttock/coccyx after being very sick with Influenza A and largely bedbound. The resident had a Braden score of 13, indicating moderate risk for pressure ulcers. Facility documentation showed the wound was first noted during a shower as an open area on the right buttock, and a subsequent skin issue report described a new in-house MASD area on the buttock with burning pain and a measured wound area, but the assessment did not clearly identify an unhealed pressure injury at that time. After the wound was identified, treatment orders were not secured promptly. The record shows barrier cream was not ordered until several days after the wound was first observed, and the treatment administration record did not show treatment started from the date the wound was identified until the barrier cream order began. The care plan also did not add new interventions when the wound was first found; those interventions were not documented until the wound doctor evaluated the resident several days later. When the wound doctor evaluated the resident, the wound was classified as a stage III pressure ulcer of the coccyx and new orders were written for calcium alginate with silver and gauze dressing. The wound clinic later documented the stage III wound with drainage and debridement. Staff interviews confirmed the wound was found during the shower, that no new treatment was entered until the barrier cream order, and that no new care plan interventions were added until the wound was reclassified as a pressure ulcer.
RN Coverage Not Provided Eight Hours Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. Review of the Nurse Schedule for January 1 through February 28, 2026 showed that no RN worked on 01/31/26, 02/14/26, 02/15/26, and 02/28/26. On 3/1/26 at 11:24 AM, the prior Director of Nursing verified that the schedules were accurate and confirmed that no RN worked on those days. The former DON stated that she was responsible for scheduling the nurses and that the facility had a hard time finding RNs to work, which was why RN coverage for eight hours per day could not be provided. The facility’s CMS Form 671 dated 3/1/26 and signed by the Administrator documented that 26 residents resided in the facility.
Food Items Left Undated and Unlabeled in Kitchen Storage
Penalty
Summary
The facility failed to ensure that food items opened in the kitchen's dry storage, refrigerator, and freezer were dated and labeled in accordance with its Food Storage (Dry, Refrigerated, and Frozen) Policy dated 3/31/25. The policy states that food shall be stored in a clean, dry area free from contaminants and that all food items will be labeled with the name of the food and the date by which it should be sold, consumed, or discarded. During a kitchen tour on 3/1/26, surveyors observed an undated and unlabeled one-gallon clear baggy containing two egg rolls in the stand-up freezer, along with a half-opened bag of frozen dinner rolls that was also undated and unlabeled. The stand-up refrigerator/freezer contained an opened 3/4 full bottle of a high calorie/high protein nutritional supplement that was undated. In a kitchen cabinet, surveyors found an opened 1/2 full 18 oz bottle of ground cinnamon and an opened 1/4 full 10 oz container of ground [NAME], both undated. The cook and the dietary manager verified that these items had been opened and should have been labeled with an open date and use-by date. The facility's CMS Form 671 dated 3/1/26 and signed by the Administrator documented 26 residents in the facility.
Delayed Physician Notification After Fall With Head Injury
Penalty
Summary
The facility failed to notify the resident’s physician in a timely manner after a significant change in condition involving a fall with a head injury. R27 fell in his room while being dressed by CNAs when he leaned back in his wheelchair and the chair tipped backward, causing him to fall onto the floor and strike the back of his head. The nurse’s assessment documented an abraded area to the back of the head, vital signs and neurological checks within normal limits, and that the resident was assisted back to bed by three staff members. Anti-tippers were applied to the wheelchair as an immediate intervention. R27 was receiving Eliquis 5 mg twice daily for chronic embolism and thrombosis of the left lower extremity at the time of the fall. The facility’s record showed the physician was not notified by phone at the time of the incident; instead, the physician was notified by fax the following day and told to continue monitoring the resident. The physician stated that a fall from a wheelchair with head impact while on a blood thinner should have been reported by phone, and the DON stated the Medical Director should have been notified by phone and could not find documentation that the physician was notified by phone.
Failure to Document Appropriate Indications for Antipsychotic Use
Penalty
Summary
The facility failed to document an appropriate diagnosis and target behaviors to support the use of antipsychotic medications for two residents with dementia. The facility’s psychotropic medication policy stated that residents should not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record, and that adequate indications for use must be documented through interdisciplinary evaluation of the resident’s physical, behavioral, mental, and psychosocial status. One resident had diagnoses including Parkinson’s disease, dementia with mood disturbance, and neurocognitive disorder with Lewy bodies, and was receiving Seroquel 50 mg twice daily. The resident’s PASRR did not show serious mental illness or intellectual/developmental disability, and the order summary listed Seroquel for dementia. The resident’s care plan did not document the antipsychotic medication, targeted behaviors, or non-pharmacological interventions related to its use. The resident was observed lying in bed or sitting calmly in the day room with no behaviors observed. A CNA stated the resident had kicked and hit staff during cares, but had not harmed self or other residents. The DON stated the only diagnosis she saw for the Seroquel was dementia, which she said was not appropriate, and verified there were no identified targeted behaviors or care plan documentation for the medication. The other resident had diagnoses including vascular dementia with mild behavioral disturbances and was receiving quetiapine 50 mg in the morning and 75 mg at bedtime for vascular dementia with behaviors. The resident’s PASRR did not show serious mental illness or intellectual/developmental disability. The care plan noted potential behaviors and sexual comments and acts, with an intervention to administer antipsychotic medication as ordered, but the resident was observed calm, pleasant, and without inappropriate behavior during meals and while in bed. The administrator/POA stated the antipsychotic was being used because dementia caused sexual inappropriateness, and nursing staff stated the resident’s only behavior was sexual comments to staff and that the resident was easily redirected.
Care Plan Not Updated for Mobility and Fall Interventions
Penalty
Summary
The facility failed to revise R26’s comprehensive care plan to reflect current interventions implemented for mobility and fall prevention. On observation, R26 was lying in bed with the bed pushed against the wall and a fall mat positioned next to the bed, and a high-back wheelchair with a foot board and stability cushion was present in the room. Review of the comprehensive care plan showed it did not include the fall mat as a fall intervention and did not document a scoop mattress. The care plan also stated that a non-slip mat was to be used in R26’s wheelchair to prevent slipping out of the chair, but no non-slip mat was observed in the wheelchair. An OTA stated R26 was no longer receiving therapy services and that staff had been repositioning R26 in the wheelchair because the resident frequently placed her legs over the side while sitting and was sliding forward and leaning; the OTA also stated a stability cushion had been implemented for this reason. The DON confirmed the fall mat, stability cushion, foot board, and scoop mattress were not included in R26’s care plan.
Failure to Provide Ordered Testosterone Gel
Penalty
Summary
The facility failed to provide ordered Testosterone Transdermal Gel for one resident who was admitted with diagnoses including age-related osteoporosis, chronic fatigue, muscle weakness, and genetic related intellectual disability. The resident’s hospital discharge medication list dated 2/6/26 documented Testosterone Transdermal Gel 20.25 mg/1.25 gm, two pumps transdermal once daily to the shoulders, and the medication was also confirmed by nursing documentation after a call to the hospital doctor’s office. A physician order dated 2/15/26 again documented Testosterone Transdermal Gel, two pumps once daily to bilateral shoulders, with a start date of 2/16/26. The medication administration record showed the order was discontinued on 2/15/26 with none of the medication given, then reordered on 2/16/26 to start at 5:00 AM. Nursing notes documented repeated attempts to clarify and obtain the medication, including contact with the primary care physician’s office on 2/23/26 regarding the script and a call to the pharmacy on 2/26/26 because the medication had not been delivered. The administrator stated the pharmacy would not fill the script because it was considered a narcotic and the doctor had to sign it, and the primary care physician did not sign the script for a couple of weeks. The pharmacist stated the order was originally entered on 2/6/26, discontinued on 2/15/26, entered again on 2/16/26, and could not be filled until a signed order was received on 2/25/26. The resident did not receive the Testosterone Transdermal Gel until 2/27/26 at 5:00 AM. On 3/1/26, the resident was observed sitting in a recliner wearing a hooded sweatshirt and covered with a blanket and was unable to answer questions appropriately.
Failure to Prevent Wheelchair Fall With Head Injury
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards and received adequate supervision and assistive devices to prevent an accident. The resident was severely cognitively impaired, required substantial to maximum assistance for transfers, and was dependent on staff for dressing. The resident also had a fall risk history and was prescribed Eliquis for chronic venous thrombosis, with a care plan identifying risk for abnormal bleeding or hemorrhage related to anticoagulant therapy. During morning care, two CNAs transferred the resident to a wheelchair using a mechanical lift. While the resident was seated in the wheelchair and staff were attempting to locate a shirt, one CNA lifted the resident’s legs to check underneath him, and the wheelchair tipped backward. The resident fell from the wheelchair and struck his head on the floor. Staff found him on the floor still in a seated position in the wheelchair, lying on his back with his head under a pillow. A head-to-toe assessment identified an abraded, dark red area on the back of the head about the size of a quarter, and the resident later had a baseball-sized discolored area on the back of the head. The record showed the resident’s physician was notified by fax rather than by phone after the fall, despite the resident being on a blood thinner and having hit his head. The physician stated that a fall from a wheelchair with head impact should have been reported by phone. The facility’s former DON and administrator stated the fall investigation witness statements were part of QA and initially did not provide the original statements; the original CNA statements later confirmed that the wheelchair tipped backward when the CNA lifted the resident’s legs to look underneath him. The DON also confirmed the fall investigation was not included in the resident’s medical record.
Failure to Replace Oxygen Tubing and Humidifier Bottle
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to replace oxygen tubing and the humidifier bottle for one resident reviewed for oxygen use. The resident had diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, and vascular dementia with other behavioral disturbances, and the care plan identified the resident as at risk for respiratory complications and requiring oxygen. During observation, the resident was sitting in his room wearing oxygen, and the humidifier bottle attached to the oxygen concentrator was dated 2/22/26. An LPN verified the date and stated the humidifier bottle should have been changed on the night shift along with the oxygen tubing. An RN stated that oxygen tubing/nebulizer equipment and humidifier bottles are to be changed every seven days on Sunday nights, and the DON stated that although she did not see that requirement in the oxygen policy, it was standard procedure and oxygen equipment is handled the same as nebulizer equipment.
Failure to Use Gown During EBP Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to apply a gown before performing high-contact care for a resident with an open wound. The facility’s Enhanced Barrier Precautions sign and policy stated that staff must wear gloves and a gown for high-contact resident care activities, including wound care, for residents with chronic wounds or indwelling medical devices. R6 had an order for a Stage II coccyx pressure sore requiring calcium alginate with silver and a border gauze dressing, changed daily and as needed for soiling or non-adherence. On 3/2/26 at 10:00 AM, an LPN entered R6’s room for wound treatment while the resident was on EBP, donned gloves, and performed the wound care to the coccyx wound, which was open and had a small amount of drainage. The LPN did not wear a gown during the procedure. At 10:07 AM, the LPN confirmed that a gown was not worn during the wound care and stated that a gown should have been worn, adding, “I knew I was forgetting something. We (staff) should be wearing gowns and gloves for any resident with an open wound.”
Residents lacked hot water in private bathrooms
Penalty
Summary
The facility failed to ensure residents had hot water available in their personal showers and sinks. The cited policy stated water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas were to be set to no more than 110 F, and the bath/shower policy directed staff to provide warm water for bathing. During the survey, the maintenance director confirmed the facility was having problems with hot water and stated the water heater sometimes worked and sometimes did not, and that a company had been called to fix it. Two residents were affected. One resident’s care plan documented a preference for showers three times weekly and a morning routine. The resident told surveyors that the bathroom in the private room no longer had hot water, that the shower and sink water were cold, and that the issue had been ongoing for about two to three weeks without a clear explanation of how long it would continue. The resident also stated a preference not to use the community shower because it would be embarrassing to go through the lobby and the building to get there. A family member stated the water in the salon was also very cold. Another resident’s care plan documented a preference for showers three times weekly and routines of preference unless changed. That resident stated there was no hot water in the bathroom for showers or the sink and that, because the water was cold, the resident was using a cold washcloth at the sink instead of showering in the room. CNAs stated the 100-hall had been without hot water for months, the 200-hall had also lost hot water, and the 300-hall was without hot water as well. Surveyor-observed temperature checks confirmed the problem: after running the water for several minutes, the shower room measured 90 F, and the shower and sink water in both residents’ bathrooms measured 65 F.
Unsafe Transfer Resulted in Skin Tear to Resident’s Affected Arm
Penalty
Summary
The facility failed to ensure a resident with hemiplegia was transferred safely to prevent a skin tear injury to the resident’s affected arm. The resident’s MDS documented that the resident required assistance of one staff member for transfers and had an upper body impairment on one side. The care plan identified diagnoses including dizziness, reduced mobility, traumatic hemorrhage of the right cerebrum without loss of consciousness, hemiplegia affecting the left dominant side, and muscle weakness, and it directed staff to assist with ambulation, transfers, and locomotion as needed. The same care plan also documented actual alteration in skin integrity with skin tears to the left antecubital forearm, and an intervention noted that a grip covering was to remain on the left arm at all times due to risk of skin injury related to left-side hemiplegia. During a transfer from the commode to the chair, a CNA and an LPN assisted the resident off the commode, but did not realize the resident’s weaker left arm had slipped under the commode armrest. As they lifted the resident, the arm remained under the rail and skin tears occurred. The CNA later stated that the resident had less control over that arm and needed staff to ensure it was in a safe position to avoid injury during transfer.
Failure to Implement Infection Surveillance and Tracking Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control surveillance program as required by its own policy. The facility's policy outlined the need for ongoing surveillance of healthcare-associated infections (HAIs) and other significant infections, including the collection of detailed data such as resident identifying information, diagnoses, admission dates, infection onset dates, infection sites, pathogens, and treatment measures. However, the facility relied on Order Listing Reports that only documented antibiotics prescribed and associated diagnoses, lacking critical information such as resident identifiers, admission dates, infection onset dates, and pathogen details. Additionally, the Infection Control Surveillance Binder did not contain line listings, infection tracking logs, or evidence of infection control tracking for staff, and did not summarize or analyze infection trends or patterns as required. Interviews confirmed that the Infection Control Surveillance Logs for both residents and staff had not been completed since July, following a change in the Director of Nursing. The interim and then permanent DON verified the absence of completed surveillance logs and tracking documentation. As a result, the facility did not have a functional system in place to identify, track, or monitor infections, communicable diseases, or outbreaks among its 27 residents and staff, as required by policy.
Lack of Qualified Infection Preventionist Designation
Penalty
Summary
The facility failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program, as required. Record review showed that the facility's staffing plan did not include an infection preventionist, despite having 27 residents. The job description for the infection preventionist position specified the need for specific training in infection prevention and control through an accredited continuing education program. During interviews, the administrator stated that the DON was assigned as the infection preventionist, but confirmed that the DON had not completed the required infection preventionist education. Oversight from regional staff occurred only once or twice a month, and the DON reported being enrolled in, but not yet having taken, the necessary infection preventionist classes.
Failure to Develop and Implement UTI Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan to address a urinary tract infection (UTI) for one resident who had a confirmed UTI, as evidenced by a urine culture showing greater than 100,000 cfu/ml Escherichia Coli and a physician's order for antibiotic treatment. Despite the facility's policy requiring a comprehensive, person-centered care plan that is updated with changes in a resident's condition, the resident's current care plan did not include any interventions or objectives related to the UTI. This omission was confirmed by the facility administrator, who acknowledged that the care plan had not been updated to address the resident's current infection.
Environmental Hazards and Maintenance Failures in Resident Shower and Bathroom Areas
Penalty
Summary
Surveyors observed multiple environmental deficiencies throughout the facility, including showers in resident bathrooms containing a brown/black furry textured substance, non-functioning water in one shower room, leaking faucets, broken and cracked tiles, exposed unconnected piping, and non-operational ventilation fans in resident rooms. These issues were found in both the North and East Halls, affecting all shower rooms and several resident rooms. The facility's own policies require a clean, safe, and homelike environment, as well as ongoing identification and mitigation of safety risks and environmental hazards. During interviews, the Administrator in Training confirmed awareness of these maintenance issues and stated that only one contractor had been contacted for repairs, with no follow-up to secure additional help despite the problems persisting for about a month. The facility census indicated that 26 residents could be affected by these environmental hazards. No information was provided regarding specific residents' medical histories or conditions at the time of the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours each day, as required. Review of staffing sheets over a one-month period revealed multiple days where no RN was present for the required duration. The facility's census documented 26 residents at the time of the deficiency. According to the Director of Nursing (DON), who is the only RN on staff, she is responsible for multiple roles including DON, MDS Coordinator, and covering the floor as needed. The DON acknowledged that due to being the sole RN, the facility was unable to meet the requirement of having an RN on duty for eight consecutive hours daily.
Failure to Use Gait Belt and Two-Person Assist During Transfer
Penalty
Summary
The facility failed to adhere to its policies regarding the use of gait belts and the requirement for a two-person assist during resident transfers, leading to a deficiency. A resident, identified as R3, who has severe mental impairment and physical limitations due to conditions such as Parkinsonism, Alzheimer's Disease, and a history of falls, was involved in an incident where they were transferred by a single CNA without the use of a gait belt. This action was contrary to the facility's Fall Policy and Gait Belt Policy, which mandate the use of a gait belt and a two-person assist for transfers to prevent accidents. The incident occurred when the CNA attempted to transfer R3, who suddenly became weak and had to be lowered to the floor. The Post Fall Investigation Report identified the root cause as the failure to use a two-person assist and a gait belt during the transfer. The resident's care plan clearly stated the need for maximum assistance with a wheeled walker and gait belt, and the resident was known to have a high fall risk due to their medical conditions and history. Despite these documented requirements, the CNA proceeded with the transfer alone, resulting in the resident being lowered to the floor, although no injuries were reported.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, R19 and R24, as observed during a survey. R24, who has an indwelling urinary catheter, did not have an EBP sign on the door, nor was there any personal protective equipment (PPE) available inside or outside the room. A Certified Nursing Assistant (CNA) provided catheter care without wearing PPE and stated that they were not informed about the requirement to use PPE for such care. This indicates a lack of communication and training regarding EBP for residents with devices that increase infection risk. Similarly, R19, who has a stage two pressure ulcer, also lacked an EBP sign and PPE availability. During wound treatment, neither the Licensed Practical Nurse (LPN) nor the CNA wore gowns, only gloves, and both were unaware of what EBP entails. The Director of Nursing/Infection Preventionist also confirmed a lack of awareness and implementation of EBP in the facility. This deficiency highlights a systemic issue in the facility's infection prevention and control program, particularly concerning the use of EBP for residents with conditions that necessitate such precautions.
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 38 citations issued within 25 miles in the last 12 months — including the 2 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 Virginia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beardstown Health & Rehab Ctr | 12.2 mi | ★★★★★ | 0 | 0 |
| Arcadia Care Jacksonville | 14 mi | ★★★★★ | 1 | 0 |
| Prairie Village Healthcare Ctr | 14.1 mi | ★★★★★ | 7 | 1 |
| Jacksonville Skld Nur & Rehab | 14.2 mi | ★★★★★ | 2 | 0 |
| Grove Health & Rehab Ctr, The | 15.1 mi | ★★★★★ | 18 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cass County Senior Living & Rehabilitation Llc.
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.