Cassville Health Care Center

In the surveyor’s words

From the most serious findings on record at Cassville Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF835Sep 10, 2025

  Based on interview and record review, the facility failed to ensure a licensed Administrator was available to the facility, that staff were aware of who the Administrator was, and that the Administrator was aware of and involved in the day-to-day happenings of the facility. This resulted in the facility not having sufficient staffing scheduled and available on-hand to ensure proper care resulting in multiple residents being left wet for extended periods of time; in staff not having access to administer ordered insulin and pain medications; allowing an unlicensed driver to transport residents; and failing to provide protective oversight of residents after a staff member was allowed to return with an investigation of allegations of misappropriation against a staff member ongoing. […]

• Immediate jeopardy, isolatedF610Sep 10, 2025

  Based on observation, interview, and record review, the facility failed to prevent any future potential abuse, neglect, exploitation, or mistreatment while an investigation of misappropriation was in progress, when the facility allowed one staff member (RN A) to return to the facility to work as the only nurse on duty causing one resident (Resident #1) to be fearful of retaliation and taking steps to leave the facility due to the fear. The facility census was 44. The Administrator was notified on 09/08/25, at 2:18 P.M., of an Immediate Jeopardy (IJ) which began on 09/08/25. The IJ was removed on 09/08/25 as confirmed by surveyor on-site verification. […]

• Actual harm, isolatedF697Sep 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to all residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, when the facility failed to ensure staff had access to administer as needed pain medication as requested for one resident (Resident #4) who showed physical and verbal signs of pain. The facility census was 44. […]

• Actual harm, isolatedF725Sep 10, 2025

  Based on interview and record review, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and allow residents to maintain their highest practicable physical, mental, and psychosocial well-being, when the facility failed to maintain a nursing schedule to ensure sufficient staff were on-site to assist all residents resulting in nurses working over 24 shifts, lack of staff on-site to meet the needs all residents, and left the building unattended for a short period of time. This resulted in residents being left wet for an extended period of time and residents feeling concern regarding their well-being. […]

• No harm, potential for more than minimal, widespreadF812Sep 24, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the facility staff failed to keep food contact and non-food contact surfaces clean; when staff failed to ensure the refrigerators maintained proper temperatures for food storage; when staff failed to ensure stored food was properly stored/sealed; and when staff failed to ensure spoiled or contaminated foods were discarded. […]