Federal inspectors found Cass County Senior Living & Rehabilitation failed to maintain infection surveillance logs from July through September 2025, violating basic infection control requirements designed to protect vulnerable elderly residents.
The facility's interim director of nursing admitted the tracking system collapsed entirely when her predecessor left in July.
"I was the interim Director of Nursing starting in July after the prior DON resigned," the current director told inspectors on September 19. "I signed as the actual Director of Nursing in September. The Infection Control Surveillance Logs for residents and staff have not been completed since July 2025."
The admission came during a complaint investigation that revealed the facility had no system for identifying which residents had infections, tracking how diseases spread, or monitoring whether treatments were working.
Instead of proper surveillance logs, the nursing director showed inspectors monthly antibiotic prescription reports from August and September. These bare-bones documents listed medications and diagnoses but contained none of the critical information required for infection control.
Missing from the facility's records were resident names, admission dates, infection onset dates, specific pathogens causing illness, and whether infections originated at the nursing home. The reports also lacked any analysis of infection patterns or trends that could signal an outbreak.
Federal regulations require nursing homes to maintain detailed surveillance systems that track every infection case individually, then compile monthly summaries by nursing unit to identify dangerous patterns. Facilities must monitor which germs are most common, where infections cluster, and how current rates compare to previous months.
The facility's own infection control policy, dated September 2027, spelled out these exact requirements. The policy mandated staff collect "identifying information, diagnoses, admission date, date of onset of infection, infection site, pathogens, invasive procedures or risk factors" for every case.
It required monthly line listings of all infections by resident, summaries by nursing unit and pathogen type, and trend analysis to "identify predominant pathogens or sites of infection among residents in the facility."
None of this happened for at least two months at Cass County Senior Living.
The surveillance breakdown meant the facility couldn't determine if residents were developing infections from contaminated equipment, poor hand hygiene, or exposure to infected roommates. Without tracking onset dates, staff couldn't distinguish between infections residents brought from hospitals and those acquired at the nursing home itself.
The missing employee infection tracking posed additional risks. Staff working while infected can spread diseases to multiple residents during a single shift, making employee surveillance crucial for outbreak prevention.
Infection control failures in nursing homes can have devastating consequences. Elderly residents with compromised immune systems face higher risks of severe complications from common infections like urinary tract infections, pneumonia, and skin wounds.
The facility houses 27 residents according to its September 19 resident listing report. All were potentially affected by the surveillance failures, inspectors determined.
The breakdown occurred during a critical transition period when the facility lacked stable nursing leadership. The interim director took over infection control responsibilities in July but didn't implement proper tracking systems until formally assuming the permanent position in September.
By then, the facility had operated without infection surveillance for at least eight weeks, creating a dangerous blind spot in resident safety monitoring.
The inspection found the facility maintained an "Infection Control Surveillance Binder" but it contained no current tracking logs, line listings, or trend analyses. The binder appeared to be a remnant of previous surveillance efforts that ended when the nursing director departed.
Without functioning surveillance systems, the facility couldn't meet federal requirements for infection prevention and control programs. These programs form the backbone of nursing home safety, designed to catch problems before they become outbreaks.
The September complaint investigation documented the surveillance failures as causing "minimal harm or potential for actual harm" to residents. However, the violation affected the facility's entire resident population during the months-long tracking gap.
Federal inspectors completed their investigation on September 21, but the facility's infection surveillance logs remained incomplete nearly three months after the system collapsed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cass County Senior Living & Rehabilitation LLC from 2025-09-21 including all violations, facility responses, and corrective action plans.
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