Cass County Senior Living & Rehabilitation Llc

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on record review and interview, the facility failed to develop and implement a plan of care to address

a resident's UTI (Urinary Tract Infection) for one of three residents (Resident R1) reviewed for UTIs in the sample of three.Findings include:The facility's Person-Centered Comprehensive Care Plan policy dated 12/2016 documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team will review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. Resident R1's Urine Culture Final Report dated 9/13/25 documents, Final Report: greater than100,000 cfu/ml (colony-forming units/milliliter) Escherichia Coli.)Resident R1's Physician's Order dated 9/13/25 documents, Ceftin 500 mg (milligrams) BID (twice daily) for seven days.Resident R1's current Care Plan does not include a plan of care to address Resident R1's current UTI.On 9/21/25 at 2:45 PM V1 (Administrator) verified Resident R1 does not have a plan of care to address Resident R1's UTI. V1 stated, (V2/Director of Nursing) is responsible for the development of (Resident R1's) UTI Care Plan.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cass County Senior Living & Rehabilitation LLC

530 East Beardstown Street Virginia, IL 62691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview the facility failed to implement a surveillance plan for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks among residents and staff.

These failures have the potential to affect all 27 residents residing within the facility.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Surveillance for Infections policy dated 09/2027 documents, The facility will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. a. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: Identifying information. Diagnoses. admission date, date of onset of infection (may list onset of symptoms, if known, or date of positive diagnostic test); Infection site. Pathogens; Invasive procedures or risk factors.

Pertinent remarks (additional relevant information). Also, record if the resident is admitted to the hospital, or expires; and Treatment measures and precautions (interventions and steps taken that may reduce risk. 1.

For targeted surveillance using facility-created tools, follow these guidelines: a. Record detailed information about the resident and infection on an individual infection report form (Infection Treatment/Tracking Report, Infection Report Form, or similar form). B. Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (Line Listing of Infections by Resident or similar form). C. Summarize monthly data for each nursing unit by site and by pathogen (Facility-Wide Monthly Infection Report by Site, Facility-Wide Monthly Infection Report by Pathogen, or similar form). D.

Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. (See Facility-Wide 12-Month Pathogen Trends or Facility-Wide 12-Month Infection Site Trends or similar tool.) E. Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period. On 9/19/25 at 1:00 PM V2 (Director of Nursing/DON) provided an Order Listing Report dated 8/2025 and 9/2025 that V2 used as the facility's infection surveillance plan and the facility's Infection Control Surveillance Binder. The Order Listing Report documents antibiotics prescribed with the diagnoses the antibiotics were prescribed for to treat for residents during this timeframe. These Order Listing Reports do not include the residents' identifying information, admission date, date of infection onset, or pathogens. The facility's Infection Control Surveillance Binder does not include line listings and infection control tracking logs for each nursing unit that include the residents' identifying information, admission date, date of infection onset, site of infection, pathogen, whether the infection was facility-acquired, sites of infection among residents in the facility or in particular units, or trends and patterns. This same Binder does not include evidence of employee infection control tracking. On 9/19/25 at 2:00 PM V2 stated, I was the interim Director of Nursing starting in July (2025) after (V13/Prior DON) resigned. I signed as the actual Director of Nursing in September (2025). V2 verified the Infection Control Surveillance Logs for residents and staff have not been completed since July 2025.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cass County Senior Living & Rehabilitation LLC

530 East Beardstown Street Virginia, IL 62691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Designate a qualified infection preventionist to be responsible for the infection prevent and control program

in the nursing home.

Based on record review and interview the facility failed to designate a qualified infection preventionist to implement the facility's infection prevention and control programs. This failure has the potential to affect all 27 residents residing within the facility.Findings include:The facility's Resident Listing Report dated 9/19/25 documents 27 residents currently reside within the facility.The facility's Infection Preventionist Job Description dated 10/12/20 documents, The Infection Preventionist is responsible for the effective direction, management, and operation of the infection prevention program. Position Qualifications and Credentials: Specific training in Infection Prevention and Control through accredited continuing education program.The facility's Facility assessment dated 2025 does not include an Infection Preventionist as part of the facility's staffing plan based on their current census and needs.On 9/19/25 at 10:45 AM V1 (Administrator) stated, (V2/Director of Nursing) is the facility's infection preventionist and is responsible for the facility's infection control program. (V4/Regional Nurse) and V5 (Regional Infection Preventionist) oversee the facility's infection control program and are on-site maybe once or twice a month. V1 verified V2 has not completed infection preventionist education.On 9/19/25 at 2:00 PM V2 stated, I have enrolled in infection preventionist class. I have not taken the classes yet.

Event ID:

Facility ID:

If continuation sheet