Cassville Health Care Center: Antibiotic Resistance Failure - MO
The inspection, completed September 10, 2025, found that a resident had been prescribed Macrobid 100 mg twice daily for ten days beginning January 31, 2026. Culture and sensitivity results, which show which antibiotics will actually work against a specific bacteria, indicated the bacteria was resistant to Macrobid. Nobody told the physician.
Staff didn't even document giving the first dose. The January medication administration record showed no entry for January 31, despite an order placed that day. A nurse did document at 6:24 that evening that Macrobid had been started and no adverse reaction was noted. She did not mention the resistance. Neither did a note from earlier that afternoon, when a Licensed Practical Nurse flagged the dosing as outside the recommended frequency but again made no mention of the resistance finding in the lab results.
The medication was then administered as ordered on February 1 and February 2, according to the February administration record. The resident was receiving an antibiotic that, by the lab's own results, would not work.
When inspectors interviewed the Director of Nursing on February 2 at 2:25 in the afternoon, the DON said he or she did not know who was monitoring lab results to ensure the bacteria was not resistant to the antibiotic prescribed, and did not know who was responsible for notifying the physician if resistance was found.
That answer alarmed the Medical Director.
Interviewed the same afternoon, the Medical Director said he or she expected nursing staff to call or text with final lab results in a timely manner and to compare those results against whatever antibiotic had been ordered. Then came the clearest statement in the entire inspection record: treating a resident with an antibiotic the bacteria was resistant to, the Medical Director said, was how antibiotic resistance is created.
Physician #1, also interviewed that day, said the same thing in simpler terms: nursing staff should review lab results and compare them to the antibiotic ordered.
A registered nurse interviewed at 4:23 that afternoon described how the process was supposed to work. Urinalysis and culture results, she said, are checked once received by a nurse, sent to the physician, and the physician then decides whether to treat. She said the culture and sensitivity is checked sometimes if the resident was initially placed on a broad-spectrum antibiotic while waiting for results, and that the DON and physician would be made aware of any resistance at that time. That's the process as she understood it. It did not happen here.
The care plan, revised February 2, listed interventions that included monitoring and documenting side effects and effectiveness each shift, reporting adverse reactions, and reporting pertinent lab results to the medical director. The lab result showing resistance to the prescribed drug was a pertinent lab result. It was not reported.
The inspection rated this deficiency as minimal harm or potential for actual harm, affecting some residents.
What the Medical Director put on the record is not a regulatory abstraction. When a bacterial infection is treated with an antibiotic it has already learned to resist, the bacteria survives and can grow more resistant still. The resident in this case was receiving a drug that the lab had already told the facility would not work, for days, while the nurses who documented her care twice on January 31 wrote nothing about what the culture results showed.
The DON, responsible for overseeing exactly this kind of clinical monitoring, could not name a single person whose job it was to watch for it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cassville Health Care Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
CASSVILLE HEALTH CARE CENTER in CASSVILLE, MO was cited for violations during a health inspection on September 10, 2025.
The inspection, completed September 10, 2025, found that a resident had been prescribed Macrobid 100 mg twice daily for ten days beginning January 31, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.