Resident 101, a woman with left-side weakness from a stroke, returned to Cass County Medical Care Facility on October 15 with hospice services already in place. The facility's own policy required a care plan within one business day. She didn't get one until October 21.
The delay exposed a breakdown in basic coordination at the 23770 Hospital Street facility. Three different staff members pointed fingers at each other when federal inspectors asked who was responsible for hospice care plans.
Director of Social Services X told inspectors she wouldn't create a care plan for Resident 101 because she hadn't coordinated the hospice services herself. "She would not create the care plan unless she coordinated the hospice services," inspectors noted.
But Registered Nurse and Unit Manager T had already told inspectors that morning that Director of Social Services X "was responsible for care plans related to hospice services."
The confusion left a dying woman without the coordinated care planning that federal regulations require within seven days of assessment — and that the facility's own policies demanded much sooner.
MDS Registered Nurse O finally created the care plan on October 21, but only after reviewing Resident 101's record during an inspection and realizing "there was not a care plan for hospice services in place." She told inspectors that Director of Social Services X "was the one that should create hospice care plans."
The care plan that emerged was minimal. It included the goal "I wish for hospice services" and a single intervention: "coordinate care with hospice staff including changes in care needs."
Director of Nursing B acknowledged the facility had fallen short. She told inspectors "her expectations were that specific care plans, such as hospice services, were created sooner rather than later in the resident's care plan."
Resident 101 had suffered a cerebral infarction due to thrombosis of the right posterior cerebral artery — a stroke on the right side of her brain caused by a blood clot. The stroke left her with weakness on her left side and qualified her for hospice care.
Hospice care plans serve as roadmaps for end-of-life care, coordinating medical treatment, pain management, and family support. Without one, facilities can miss critical changes in a dying patient's condition or fail to adjust care as needs evolve.
The facility's own staff acknowledged care plans should be created "within the next business day or as soon as possible," according to Unit Manager T. Federal regulations allow up to seven days, but most facilities aim for faster turnaround to ensure dying patients receive appropriate care.
The October 21 inspection found that while Resident 101 was seen by a hospice nurse on October 15, her care wasn't properly integrated into the facility's systems until six days later.
Director of Social Services X drew a distinction between creating "clinical interventions for hospice care" and coordinating services, telling inspectors she was responsible only for coordination. But her refusal to create any care plan left Resident 101 without the basic framework required by federal law.
The violation represents what inspectors classified as "minimal harm or potential for actual harm" affecting "few" residents. But for families watching loved ones die, even minimal delays in care planning can feel devastating.
Federal inspectors reviewed three residents' care plans during the November 21 complaint investigation. Resident 101 was the only one whose plan wasn't revised in a timely manner.
The facility must now submit a plan of correction explaining how it will prevent future delays in hospice care planning. The state will monitor compliance to ensure dying patients receive the coordinated care they're entitled to under federal law.
Cass County Medical Care Facility has 14 days from receiving the inspection report to make its corrective action plan public.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cass County Medical Care Facility from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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