Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 10 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.