Federal inspectors found Cass County Senior Living & Rehabilitation failed to create the required treatment plan for a resident whose urine culture showed dangerous levels of E. coli bacteria on September 13.
The resident's lab results documented "greater than 100,000 cfu/ml Escherichia Coli" — a bacterial count indicating a significant infection requiring immediate medical attention.
A physician ordered Ceftin 500 milligrams twice daily for seven days the same day the culture results came back positive.
But the facility never updated the resident's care plan to address the UTI diagnosis or treatment protocol.
Administrator V1 confirmed to inspectors on September 21 that no UTI care plan existed for the resident. The administrator said the Director of Nursing was responsible for developing the missing treatment plan.
The facility's own policy requires comprehensive care plans with "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs." The policy mandates care plan updates when residents experience significant changes in their medical condition.
UTIs in nursing home residents require careful monitoring beyond antibiotic administration. Proper care plans typically include fluid intake goals, bathroom assistance schedules, hygiene protocols, and symptom tracking to prevent complications or recurrence.
The inspection occurred following a complaint about the facility's practices.
Federal regulations require nursing homes to provide appropriate care for residents with bladder and bowel conditions, including prevention and treatment of urinary tract infections. Care plans serve as roadmaps for staff to ensure consistent, coordinated treatment approaches.
Without a formal care plan, nursing staff lack specific guidance on monitoring the resident's response to treatment, tracking symptoms, or implementing preventive measures to avoid future infections.
The facility's policy documents state that interdisciplinary teams must review and update care plans when desired outcomes aren't met, when residents return from hospital stays, and at least quarterly during required assessments.
E. coli infections in the urinary tract can lead to serious complications in elderly residents, including kidney infections, sepsis, or bloodstream infections if not properly managed and monitored.
The missing care plan represents a breakdown in the facility's treatment coordination system, leaving staff without clear protocols for managing an active infection requiring daily medication administration.
Inspectors reviewed UTI care for three residents during their visit and found deficiencies in one case. The review was part of a broader examination of the facility's infection prevention and treatment practices.
The resident continued receiving the prescribed antibiotic treatment despite the absence of a formal care plan documenting treatment goals, monitoring requirements, or staff responsibilities.
Federal surveyors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the deficiency highlights gaps in the facility's care planning process for residents with active medical conditions.
The facility must submit a plan of correction detailing how it will address the care planning failure and prevent similar oversights in the future.
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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