Cass County Medical Care Facility

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #2641076Based on interview and record review the facility failed to revise a person-centered care plan timely for 1 (Resident #101) of 3 residents reviewed for care plan revisions, resulting in the potential for unmet care needs. Findings include:Resident #101Review of an admission

Record revealed Resident #101 was a female who originally admitted to the facility on [DATE REDACTED] and had pertinent diagnoses which included: Cerebral infarction due to thrombosis of the right posterior cerebral artery (stroke on the right side of the brain due to a blood clot resulting in left side weakness).Review of Order Summary for Resident #101 revealed Name Omitted Hospice service to eval and tx (evaluate and treat) with a start date of 10/15/25.Review of Health Status Note for Resident #101 dated 10/15/25 revealed .seen by hospice nurse this shift.Review of Care Plan for Resident #101 revealed .Focus/goal/interventions.I wish for hospice services.intervention: coordinate care with hospice staff including changes in care needs. Initiated on 10/21/25.In an interview on 10/21/25 at 11:45 AM, Registered Nurse/Unit Manager (RN/UM) T reported Resident #101's hospice care plan was added today and when queried, RN/UM T reported care plans should be entered within the next business day or as soon as possible. RN/UM T reported that Director of Social Services (DSS) X was responsible for care plans related to hospice services. In an interview on 10/21/25 at 12:32 PM, DSS X reported she will initiate hospice care plans related to the coordination of services, she would not create clinical interventions for hospice care.

DSS X reported Resident #101 readmitted to the facility with hospice services in place, she did not coordinate the service, and she would not create the care plan unless she coordinated the hospice services.In an interview on 10/21/25 at 12:46 PM, Minimum Data Set/Registered Nurse (MDS/RN) O reported she created Resident #101's hospice care plan today when she reviewed her record, noted the order for hospice services and realized there was not a care plan for hospice services in place. MDS/RN O reported that DSS X was the one that should create hospice care plans.In an interview on 10/21/25 at 12:01 PM, Director of Nursing (DON) B reported her expectations were that specific care plans, such as hospice services, were created sooner rather than later in the resident's 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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cass County Medical Care Facility

23770 Hospital St Cassopolis, MI 49031

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)

Federal health inspectors cited Cass County Medical Care Facility in Cassopolis, MI for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2025-11-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of Cass County Medical Care Facility.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-17.