Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cass County Medical Care Facility during CMS and state inspections, most recent first.
A resident with dementia and Parkinsonism reported that a male CNA sexually assaulted her during the night, and staff interviews, voicemail messages, and camera footage showed the CNA entering her room and remaining inside with the door closed. The resident was fearful and anxious afterward, did not want the CNA around her, and the police report identified the CNA as the suspect for sexual penetration. Another resident also said the CNA made her feel uncomfortable and did not want him to provide care.
Food Storage, Sanitation, and Warewashing Deficiencies Surveyors found multiple food safety issues in the kitchen, including improperly date-marked ready-to-eat foods in the walk-in cooler and Nutrition Kitchen, open items with missing or expired discard dates, and in-house items such as tartar sauce and prune pudding cups that were not handled in accordance with FDA Food Code date-marking rules. They also observed crumbs, debris, and dried food buildup in utensil drawers, on a scoop stored with clean utensils, and on the slicer, along with plumbing concerns at the 3-comp sink and dish room faucet, inconsistent dish machine rinse pressure, and no irreversible registering temp indicator for the warewasher. On revisit, a pan of soup being cooled in the walk-in cooler was still 132F after being placed there earlier in the day.
Oxygen flow rates were not consistently set according to physician orders for three residents with respiratory conditions. One resident with COPD and respiratory failure had oxygen running at 4 L/min on the concentrator and 3 L/min on a portable device despite an order for 2 L/min continuous. A second resident with vascular dementia and asthma had oxygen running at 3 L/min instead of 2 L/min continuous, and a third resident with COPD, asthma, and chronic respiratory failure had oxygen running at 2.5 L/min instead of 2 L/min at HS and PRN. Staff, including an LPN and the DON, confirmed the settings were incorrect.
Failure to assess a resident for self-administration of an inhaler. A cognitively intact resident with COPD and chronic respiratory failure had an inhaler left at the bedside and reportedly used it on his own time, but the chart had no self-administration assessment or care plan. Staff gave conflicting accounts: one LPN said the inhaler was usually left at the bedside because the resident knew how to use it, while the DON and RN acknowledged that an assessment should have been completed and documented.
Delayed Dental Follow-Up and Poor Oral Hygiene: A resident with stroke-related deficits and chronic periodontitis had no upper teeth, discolored lower teeth, bleeding gums, and tartar buildup. Although a dental referral and outside consult were documented, staff gave conflicting accounts about who was responsible for scheduling, the referral was delayed, and the resident’s family reported unanswered calls and uncertainty about the planned dental care.
Delayed Hospice Care Plan Revision: A resident with a stroke-related diagnosis had hospice services ordered and was seen by the hospice nurse, but the hospice care plan was not added until several days later. Staff interviews showed confusion over who was responsible for creating the hospice care plan, and the DON stated such care plans should be created sooner rather than later.
Failure to supervise a high-fall-risk resident led to a fall with a pelvic fracture. The resident had repeated falls, dizziness, weakness, and moderate cognitive impairment, and therapy had assessed him for SBA/supervision rather than independence. Staff described him as impulsive and self-transferring, but this was not documented in the record or care plan. An RN observed him lose balance while walking with a walker, fall backward, hit his head on a bed footboard, and land on the floor; surveyors also observed him self-transfer without assistance and noted a call light left unanswered for 13 minutes.
The facility failed to maintain sanitary conditions and ensure proper labeling and dating of foods in the kitchen and resident refrigerator, leading to potential foodborne illness risks. Observations revealed unlabeled and expired food items, lime buildup on a coffee machine spout, and unsealed food in storage. Staff interviews confirmed non-compliance with labeling and expiration protocols.
The facility failed to maintain an active water management plan and proper infection control practices. Staff did not adhere to PPE protocols for residents requiring enhanced barrier precautions, and dietary aides neglected hand hygiene during meal service, increasing the risk of infection and cross-contamination.
The facility failed to provide a dignified dining experience for four residents, leading to disappointment. Observations revealed that multiple residents were seated without meals, with no order in tray delivery. A CNA noted delays for special meals, and residents with significant medical conditions received their meals later than others. A resident reported her meal ticket was placed at the bottom despite arriving early, causing her to eat separately from her tablemates. The Dietary Manager acknowledged unnecessary delays in serving alternate meals despite adequate staffing.
A resident was denied the use of a 40-inch television in her room, despite it fitting the available space, leading to frustration and headaches. The facility did not explore alternative mounting options, citing bracket size limitations and maintenance department discretion.
The facility failed to accommodate a resident's choice to spend time outdoors independently, despite the resident being cognitively intact and capable of making her own decisions. Staff enforced a policy requiring supervision for outdoor activities, which contradicted the resident's preferences and initial admission information.
The facility failed to assist a dependent resident with getting out of bed for meals, despite the care plan indicating the need for such assistance. Observations and interviews revealed that the resident remained in bed during meal times, and there was a discrepancy between staff understanding and the Infection Preventionist's report on the resident's mobility and dining room access.
The facility failed to provide individualized activities for three residents, leading to feelings of boredom, loneliness, and social withdrawal. One resident with aphasia and hemiplegia spent most of his time in bed despite expressing interest in outdoor activities and music. Another resident with low vision and chronic pain was not provided with audiobooks or other accommodations to engage in religious activities and sports. A third resident with autism and depression spent most of his time in bed, with minimal engagement in activities despite his interest in music and drawing.
A resident with multiple diagnoses, including severe malnutrition and muscle weakness, did not receive consistent pressure ulcer prevention measures, leading to ongoing skin breakdown and pain. The resident was observed without prescribed heel protector boots, and his bed was not adjusted to prevent pressure on his feet. Nursing staff failed to communicate skin assessments to the wound care nurse, resulting in inadequate wound care.
The facility failed to maintain standard infection control practices during incontinence care for two residents, resulting in improper hand hygiene and glove use. One resident was on contact precautions for C. Diff, and another was on Enhanced Barrier Precautions due to chronic wounds. Staff did not perform hand hygiene after removing soiled gloves and before donning clean gloves, and an RN entered a resident's room without a gown.
Failure to Protect Resident from Staff Sexual Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from staff-to-resident sexual abuse. Resident #1 was an elderly woman with Parkinsonism and dementia, and her BIMS score of 10 out of 15 indicated moderately impaired cognition. She was dependent for ADLs such as toileting and showering. The report states that she was transferred to the hospital for a SANE exam after reporting that a male CNA sexually assaulted her, and she did not return to the facility. According to the facility’s incident narrative and staff interviews, the resident told multiple staff members that a black male entered her room during the night, penetrated her vagina, and ejaculated. Her account varied somewhat across interviews, but she repeatedly described sexual contact and said she was scared. The charge nurse reported hearing the resident yell for help and seeing the CNA outside the room. Other staff members reported that the resident was anxious, did not want the CNA in her room, and later stated that she did not want him to take care of her. The resident’s family member reported that the resident left voicemails describing a black man in her room and asking for help. Camera footage showed the CNA entering the resident’s room around 11:00 PM, obtaining gloves, closing the door, and remaining inside for about 10 minutes before exiting with gloves and a washcloth. The CNA stated he provided peri care to the resident during the night, while documentation showed toileting hygiene care was recorded only once at 3:29 AM by another CNA and no other toileting care was documented during the overnight period. The police were called, the resident’s linens and clothing were bagged as evidence, and the police report identified the suspect as the CNA for sexual penetration. The report also notes that another resident stated the CNA made her feel uncomfortable and looked at her in a way that made her not want him to care for her.
Food Storage, Sanitation, Plumbing, and Warewashing Deficiencies
Penalty
Summary
The facility failed to maintain food storage and date-marking practices in the kitchen and walk-in cooler. During an initial tour, surveyors found a large bowl of tartar sauce dated 4/8 to 5/8 and were told by the Certified Dietary Manager (CDM) that it was made in house. The cooler also contained an open package of hot dogs with no legible discard date, an open package of sliced turkey dated 4/28 to 5/3, and a chunk of ham dated for discard on 5/2. In the Nutrition Kitchen, surveyors found individual prune pudding cups dated 4/10 to 5/10, and the CDM stated this item was also made in house. The report cited FDA Food Code requirements for date marking and disposal of ready-to-eat time/temperature control for safety foods. Surveyors also observed sanitation problems with food-contact and nonfood-contact surfaces. The clean utensil drawers containing whisks and spatulas had an accumulation of crumbs and debris in the back of the drawers, and a gray mechanical scoop stored with clean utensils had dried food accumulation. The slicer had dried meat debris on the backside, bottom, top portions of the blade, and back components, and the CDM stated it had not been used that day and was only used once or twice a week. A production area utensil drawer also had crumb debris in the back. The report cited FDA Food Code requirements that equipment, food-contact surfaces, utensils, and nonfood-contact surfaces be kept clean. Additional observations involved dish room plumbing and warewashing equipment. The overhead spray at the three-compartment sink was resting on the running boards in a way that placed it below the overflow rim of the sink, creating a plumbing cross connection from potable and wastewater. At the wall-mounted spray in the dish room, a Y valve was on the faucet hose bib and the hose was left on, leaving the faucet’s internal vacuum breaker under constant pressure; a sign above the faucet instructed staff to turn off the water when not in use. Surveyors also found the dish machine rinse pressure gauge missing its glass cover and giving inconsistent readings between 25 and 45 PSI, while the machine required 20 PSI during the rinse cycle. The CDM stated they did not have the means to ensure proper dish machine temperature by using an irreversible registering temperature indicator. On revisit, surveyors found a full six-inch-deep quarter pan of soup of the day in the walk-in cooler on a cart covered in saran wrap; the CDM stated the soup was made every morning, used for lunch and dinner, and was cooled after lunch so it could be reheated for dinner. The soup temperature was 132F after being placed in the cooler around 1:00 PM, and the report cited FDA Food Code cooling requirements.
Oxygen Flow Rates Not Set According to Orders
Penalty
Summary
The facility failed to ensure oxygen orders were followed consistently for three residents who had physician-ordered oxygen therapy. Resident #57 had diagnoses including COPD, acute and chronic respiratory failure with hypoxia, dyspnea, and dependence on supplemental oxygen, with an order for oxygen at 2 L/min via nasal cannula continuously. Resident #53 had vascular dementia and asthma, with an order for oxygen at 2 L/min via nasal cannula continuously. Resident #25 had COPD, asthma, and chronic respiratory failure with hypoxia, with an order for oxygen at 2 L/min via nasal cannula at bedtime and as needed. During multiple observations, Resident #57’s oxygen concentrator was found running at 4 L/min, and her portable oxygen concentrator displayed a setting of 3, which the DON confirmed translated to 3 L/min. Resident #53 was observed on multiple occasions with her oxygen concentrator running at 3 L/min instead of the ordered 2 L/min. Resident #25 was observed on multiple occasions with her oxygen concentrator running at 2.5 L/min instead of the ordered 2 L/min. In each case, the residents reported the oxygen flow rate was supposed to be 2 L/min, and staff confirmed the residents would not have changed the settings themselves. LPN G confirmed that Resident #57’s concentrator should have been set to 2 L/min and not 4 L/min, and that Resident #53’s concentrator was set incorrectly at 3 L/min instead of 2 L/min. The facility’s oxygen policy stated that oxygen tubing and supplies would be set up according to physician orders and manufacturer or supply company directions, and that new tubing with tank and/or concentrator would be used when first setting up oxygen therapy per physician order for liters per minute.
Failure to Assess Resident for Self-Administration of Inhaler
Penalty
Summary
The facility failed to ensure that a resident was assessed as appropriate for self-administration of an inhaler. The resident had diagnoses of COPD and chronic respiratory failure with hypoxia and was cognitively intact with a BIMS score of 14 out of 15. During observation, the resident was lying in bed with an inhaler on the bedside table, and the resident stated he was done using it and that the nurse was coming to get it. The physician order was for Incruse Ellipta inhalation powder, 1 inhalation daily for COPD, but the resident’s chart contained no self-administration assessment and no care plan for self-administration of medication. Interviews showed conflicting practices regarding the inhaler. An LPN stated there were no residents on the hall who could self-administer medications, but also said she usually left the inhaler at the resident’s bedside because he knew how to use it and rinse his mouth afterward. The resident stated the nurse left the inhaler by his bedside so he could take it when he was ready and had done so many times before. The DON and an RN stated there were no residents in the facility who could self-administer medications, acknowledged that an inhaler is a medication and that a self-administration assessment should have been completed, and stated it should have been documented in the chart. Another LPN stated she stood at the resident’s bedside when he took the inhaler because it was a medication and could not be left at the bedside.
Delayed Dental Follow-Up and Poor Oral Hygiene
Penalty
Summary
The facility failed to follow up and provide prompt dental services for Resident #6, who had a history of cerebral infarction, right-sided hemiplegia, and chronic periodontitis. The resident’s BIMS score was 11 out of 15, indicating moderately impaired cognition. During observation, the resident had no upper teeth and the lower teeth were brown and black, and she indicated with a thumbs up that she wanted the surveyor to look into dental services. She was also noted to have bleeding gums and poor dental hygiene. The record showed a physician order allowing the resident to see a dentist as desired and a dental referral for bleeding gums. A progress note documented that the resident’s husband was spoken to about the dental referral and was on board with her being seen at an outside dental office. Another note showed a follow-up call to the dental clinic, and an outside dental consult later documented a complete layer of tartar, inability to fully visualize the lower teeth, and a recommendation that the resident be brought to the dental clinic at the next visit for cleaning and evaluation. A later progress note still described the bottom right lower teeth as discolored and dark. Interviews showed confusion and lack of follow-through regarding who was responsible for scheduling and coordinating the dental care. The LPN stated the husband said he did not want the resident to see a dentist and that she agreed with whatever he decided. The DSS stated the resident was signed up for dental services and that the dentist usually followed up after seeing residents, but did not do so this time. The WC stated the referral had been on hold because appointments at the University of Michigan were delayed for 6 to 8 months and said she did not schedule the ancillary service recommendations. The family member stated the resident was supposed to be sent for dental treatment because of bleeding gums and pain, but he was unsure what happened and said his calls to the facility were not returned.
Delayed Hospice Care Plan Revision
Penalty
Summary
The facility failed to revise a person-centered care plan timely for Resident #101, who was a female admitted with diagnoses including cerebral infarction due to thrombosis of the right posterior cerebral artery, resulting in left-sided weakness. Review of the record showed an order for hospice services to evaluate and treat with a start date of 10/15/25, and a health status note on 10/15/25 documented that the resident was seen by the hospice nurse that shift. However, the care plan entry for hospice services was not initiated until 10/21/25, and the hospice-related intervention was documented as coordinating care with hospice staff including changes in care needs. During interviews, the RN/UM stated the hospice care plan was added on 10/21/25 and said care plans should be entered within the next business day or as soon as possible. The DSS stated she would initiate hospice care plans related to coordination of services but would not create clinical interventions, and said she did not create the care plan because she did not coordinate the hospice services. The MDS/RN stated she created the hospice care plan after reviewing the record and noticing there was no care plan in place, and the DON stated her expectation was that specific care plans such as hospice services were created sooner rather than later.
Failure to Supervise a High-Fall-Risk Resident
Penalty
Summary
The facility failed to maintain adequate supervision for a male resident with a history of repeated falls, dizziness, weakness, and moderate cognitive impairment. His care plan identified him as high risk for falls and injury, with interventions including call light use, proper footwear, and therapy referral. Therapy documentation showed he was assessed for stand by assistance and supervision for transfers, and therapy staff reported he was never assessed as independent during his stay. However, nursing staff and other staff members described him as impulsive, self-transferring, and ambulating on his own in his room, while these behaviors were not documented in his record or care plan. On the day of the incident, an RN observed the resident ambulating in his room with his walker and losing his balance. The RN reported the front wheels of the walker came off the floor, the resident fell backward, struck his head on the footboard of another bed, and landed on his bottom. He was sent to the hospital and was diagnosed with a left pubic rami fracture. The RN stated she believed he was independent in his room with his walker and did not think any intervention could have been done because of that assumption. Additional observations and interviews showed the resident continued to self-transfer from his wheelchair to his recliner and would get up on his own to go to the bathroom. Staff stated they knew he would self-transfer and would follow him to his room after meals, but the record did not document impulsive behavior or self-transferring. During survey observation, the resident was seen transferring himself from his wheelchair into his recliner without assistance. The report also noted a room call light remained active for 13 minutes before being answered, despite staff being nearby and receiving call light notifications on their mobile phones.
Failure to Maintain Sanitary Conditions and Proper Food Labeling
Penalty
Summary
The facility failed to maintain sanitary conditions and ensure proper labeling and dating of foods in both the kitchen and the resident refrigerator in the activity room. During an initial kitchen tour, a coffee machine spout was found with lime buildup, which was not cleaned by the following day. Additionally, several food items in the kitchen were observed without proper labels and dates, including bowls of ice cream, cups of specialty drinks, and containers of soups, all of which were past their expiration dates. Further observations revealed that the dry storage room contained unsealed bags of orzo and flour without labels or dates, and the cook's refrigerator had various food items such as a salad, milk carton, and mozzarella cheese that were not sealed or labeled. The bottom of the refrigerator was also dirty with crumbs. Interviews with dietary staff confirmed that food items should have been labeled and dated, and expired food should have been discarded. The facility's failure to adhere to the 2022 FDA Food Code and its own Date Marking for Food Safety Policy resulted in the potential spread of foodborne illness to residents. The policy required that perishable food items be clearly marked with the date of preparation and the date by which they should be consumed or discarded. However, the facility did not comply with these guidelines, as evidenced by the numerous unlabeled and expired food items found during the survey.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. Upon review of the facility's Water Management Plan, it was found that there was no documentation of a team of staff members meeting to discuss water management, no test results, and no completed risk assessment. The Maintenance Director, who was new to the position, was unaware of the necessary actions related to the water management plan and had not conducted any evaluations or established control measures for the facility's water system. The facility also failed to maintain proper infection control practices, particularly in the use of personal protective equipment (PPE) in enhanced barrier precaution settings. Two residents, one with a suprapubic catheter and another with osteomyelitis and a urinary tract infection, were not provided care with the appropriate PPE. Staff members were observed not wearing gowns during high-contact activities such as emptying catheter drainage bags and repositioning residents, despite the facility's policy and CDC guidelines requiring such precautions. Additionally, the facility did not adhere to proper hand hygiene practices during meal service in the dining room. Dietary aides were observed serving meals and handling utensils without performing hand hygiene between tasks, increasing the risk of cross-contamination and disease transmission. Interviews with staff revealed a lack of consistent understanding and implementation of hand hygiene protocols, despite the facility's policy and training requirements.
Delayed Meal Service Compromises Dignity in Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for four residents, resulting in feelings of disappointment. During an observation, it was noted that multiple residents were seated in the dining room without receiving their meals, and there was no particular order for meal tray delivery. Certified Nursing Assistant (CNA) U mentioned that a resident who had ordered a special meal was delayed because it took longer to cook. Several residents, including those with significant medical conditions such as dementia, diabetes, paralysis, malnutrition, dysphagia, and cognitive communication deficits, were observed receiving their meals significantly later than their tablemates. Resident #40 reported that despite arriving early to the dining room, her meal ticket was placed at the bottom, causing her to eat separately from her tablemates. The Dietary Manager (DM) TT acknowledged that the delay in serving alternate meals was unnecessary given the staffing levels and reported that residents were given soup, side salad, or cottage cheese to occupy them while waiting. The report highlights the lack of coordination in meal delivery, which led to a compromised dining experience for the residents involved.
Failure to Allow Use of Personal Belongings
Penalty
Summary
The facility failed to maintain the dignity of a resident by denying her the right to use personal belongings of choice in her room. The resident, who was cognitively intact and had a history of major depressive disorder and occipital neuralgia, was not allowed to use a 40-inch television that her daughter had purchased for her. The facility's reason for this denial was that the wall-mounted brackets could only accommodate a 32-inch television. Despite the resident's offer to purchase larger brackets, the facility did not explore other options for mounting the television or changing the location of the television bracket. This resulted in the resident experiencing frustration and disappointment, as well as headaches from trying to watch the smaller television provided by the facility. Observations revealed that the resident spent significant time sitting at the edge of her bed, staring straight ahead, indicating a lack of engagement in activities. Interviews with the Social Services Director and Assistant confirmed that the facility had no specific restrictions on personal belongings unless they posed a safety hazard. However, they did not make any attempts to resolve the issue of mounting the larger television. Measurements of the television space in the resident's room confirmed that it could accommodate the 40-inch television, yet the facility still refused to allow its use, citing the discretion of the maintenance department.
Failure to Accommodate Resident's Outdoor Preferences
Penalty
Summary
The facility failed to allow and accommodate a resident's choice to spend time outdoors by themselves, impacting Resident #6, who was cognitively intact with a BIMS score of 15. Despite Resident #6's clear preference and capability to go outside independently, the facility enforced a policy requiring staff or family supervision for outdoor activities. This restriction was communicated to Resident #6 upon admission, but later contradicted by the facility's practice, leading to Resident #6 being unable to go outside alone as she wished. Interviews with various staff members, including the receptionist, CNA, activity aide, and social services director, confirmed that the facility did not permit any residents to go outside unaccompanied. The social services director acknowledged that Resident #6 was her own decision-maker and should not need supervision to go outside. The facility had not considered allowing residents to go outside independently until the issue was raised by Resident #6, who later reported that staff had discussed changing this policy with her, allowing her to go outside on her own.
Failure to Assist Resident with Getting Out of Bed
Penalty
Summary
The facility failed to provide assistance with getting out of bed for a dependent resident, Resident #55, who was reviewed for Activities of Daily Living (ADL) care. Resident #55, diagnosed with Down syndrome, was dependent on staff for eating and transferring out of bed, as indicated in the Minimum Data Set (MDS) assessment. Despite the care plan indicating that Resident #55 should be assisted back to bed after being in a chair for more than two hours and should only be up for meals, observations revealed that Resident #55 remained in bed during multiple meal times and was not assisted out of bed as required. Interviews with Certified Nursing Assistants (CNAs) and the Infection Preventionist (IP) confirmed that Resident #55 was not getting out of bed for meals, even though she could be up in her chair for two hours and could go to the dining room despite being positive for C. Diff. The observations and interviews indicated a lack of adherence to the care plan for Resident #55, who was observed lying in bed during various times, including meal times, and was not assisted out of bed. The CNAs reported that Resident #55 did not get out of bed for meals anymore, and there was a discrepancy between the CNAs' understanding and the Infection Preventionist's report that Resident #55 could still go to the dining room for meals. This failure to provide the necessary assistance with getting out of bed potentially impacted Resident #55's ability to meet her highest practical level of well-being.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities based on resident preferences, needs, and abilities for three residents, resulting in feelings of boredom, and a potential for loneliness, social withdrawal, and depressed mood. Resident #65, a male with aphasia and hemiplegia following a stroke, expressed a desire to go outside, listen to crime novels on audiobooks, and enjoy rap and rhythm and blues music. Despite these preferences being documented, the resident was observed spending most of his time in bed or in a dark room, with minimal participation in activities. Interviews with family members and staff confirmed that Resident #65 was not engaged in meaningful activities and appeared withdrawn and possibly depressed. Resident #69, a male with glaucoma, chronic pain, and severe protein-calorie malnutrition, was noted to have low vision and difficulty participating in activities. Despite his interest in religious activities, jazz music, and sports, there was no evidence that the facility provided audiobooks or other accommodations to help him engage in these activities. Observations showed Resident #69 spending most of his time in bed with the television on low volume, and he was unaware of group activities such as the all-month birthday celebration. Resident #63, a male with autism, depression, and a developmental disorder, enjoyed playing music, drawing, and being outside. However, he was observed spending most of his time in bed, with minimal engagement in activities. Family members and staff reported that Resident #63's participation depended on how he was approached, and he often declined activities. Despite this, there was no documentation indicating that he was invited or encouraged to attend religious or outdoor activities. The facility's activity logs and interviews with staff revealed a lack of individualized and meaningful engagement for Resident #63, contributing to his social withdrawal and agitation.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement interventions to prevent skin breakdown for a resident at risk for pressure ulcers. Resident #69, a male with multiple pertinent diagnoses including glaucoma, chronic pain, severe protein-calorie malnutrition, and muscle weakness, was observed without the prescribed heel protector boots on multiple occasions. The resident's care plan included interventions such as heel protector boots while in bed and a standard turning and repositioning program, but these were not consistently followed. Observations revealed that the resident's feet were often in contact with the footboard of the bed, and his positioning was not adequately adjusted to prevent pressure ulcers. The resident's medical records indicated that he had wounds on his toes, which were being treated with betadine. Despite this treatment, the resident reported that his toes were painful and did not appear to be healing. Multiple observations confirmed the presence of wounds on both feet, with scabbed and open areas on several toes. The resident's bed was not adjusted to accommodate his height, leading to further pressure on his feet. Maintenance staff confirmed that the bed could be extended but required a work order from nursing staff, which had not been initiated. Interviews with nursing staff revealed that the resident's skin assessments were not adequately communicated to the wound care nurse, and the resident was not included in the wound care nurse's rotation. The wound care nurse confirmed that the wounds appeared to be pressure ulcers and that the resident should have been on her rotation. The lack of consistent implementation of preventive measures and inadequate communication among staff contributed to the resident's ongoing skin breakdown and pain.
Failure to Maintain Infection Control Practices During Incontinence Care
Penalty
Summary
The facility failed to maintain standard infection control practices during incontinence care for two residents, resulting in improper hand hygiene and glove use. For Resident #55, who was on contact precautions due to a recent positive test for C. Diff, two CNAs changed gloves multiple times during care without performing hand hygiene before donning clean gloves. They also washed their hands for only 10-15 seconds, which is insufficient. The Infection Preventionist confirmed that staff were expected to perform hand hygiene after removing soiled gloves and before donning clean gloves to prevent cross-contamination. For Resident #58, who was on Enhanced Barrier Precautions due to chronic wounds, two CNAs and an RN failed to follow proper infection control protocols during incontinence care. One CNA removed soiled gloves, touched a door knob, and obtained clean washcloths without performing hand hygiene before donning clean gloves. The same CNA continued to handle clean items and the resident's urinary catheter with soiled gloves. Additionally, an RN entered the room without a gown and leaned on the resident's bed while wearing gloves. The Infection Preventionist confirmed that staff should perform hand hygiene every time they remove soiled gloves and when transitioning from dirty to clean areas during care.
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What surveyors actually found near you
We read the 399 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
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Nursing homes near Cassopolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Timbers Of Cass County | 8.5 mi | ★★★★★ | 20 | 0 |
| Niles Care Center, Llc | 12.4 mi | ★★★★★ | 31 | 0 |
| The Orchards At Niles | 12.8 mi | ★★★★★ | 1 | 0 |
| East Lake Nursing & Rehabilitation Center | 13 mi | ★★★★★ | 9 | 0 |
| Greenleaf Health Campus | 13.4 mi | ★★★★★ | 1 | 0 |
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