Cassville Health Care: Delayed Blood Clot Testing - MO
The incident began October 24, 2025, when LPN F found the bruise during routine care. The nurse described it as being in "an odd place" and immediately applied ice to reduce swelling. But critical steps to rule out a dangerous blood clot were delayed for days.
The resident complained of pain when moving the leg and walking. The bruise was smaller than a softball but larger than an apple, according to the director of nursing who was notified that same day.
LPN F texted the resident's physician about the discovery but received no response. No orders for diagnostic testing came through. The nurse documented the injury as an "unwitnessed bruise of unknown origin" on a risk assessment form, following instructions from the director of nursing.
Three days passed before proper medical orders were entered.
The delay created confusion about what actually happened. LPN F documented that the resident had fallen, but the director of nursing told inspectors there was no indication of any fall. The resident required standby assistance only for showers and was independent with all other care activities.
"The nurse should have completed a skin assessment upon discovery of the bruise on 10/24/25," the director of nursing told inspectors during interviews in November. "The bruise should have been monitored every shift until it resolved."
When diagnostic orders were finally entered on October 27, another problem emerged. The order was entered incorrectly, causing the lab technician to arrive with wrong equipment and forcing a rescheduled appointment.
The director of nursing blamed the delay on this mix-up, telling inspectors the technician "brought the wrong equipment on 10/27/25 and had to reschedule the visit." But the ultrasound company representative contradicted this account when interviewed by inspectors.
"There were no notes showing a technician brought the wrong equipment and had to reschedule the appointment," the company representative said. Their records showed only one order for the resident, placed October 27, and only one visit, completed October 28.
The testing ultimately took place four days after the bruise was discovered.
Other nurses at the facility described the proper protocol when interviewed by inspectors. LPN B said nurses should assess and monitor residents, obtain vital signs, conduct neurological assessments, and notify the director of nursing, family, and physician for any change of condition. All information should be documented in progress notes.
LPN D explained the standard response to discovering a large bruise: complete an incident report in the electronic medication record, notify the physician and director of nursing, and report the finding to the next shift nurse for continued monitoring.
None of these steps happened promptly in this case.
The resident's bruise began decreasing in size after ice application, but the missed opportunities for immediate assessment and monitoring violated facility protocols. Federal inspectors found the facility failed to ensure residents received proper medical care when their condition changed.
The director of nursing acknowledged multiple failures during inspector interviews. The facility should have monitored the bruise every shift until resolution. The nurse should have documented physician notifications regarding test results. Most critically, a proper skin assessment should have been completed immediately upon discovering the suspicious injury.
The case illustrates how communication breakdowns and delayed responses can compromise resident safety. A large, unexplained bruise in an unusual location, combined with pain during movement, warranted immediate medical evaluation to rule out serious complications like blood clots.
Instead, the resident endured days of uncertainty while staff struggled with documentation errors, communication failures, and delayed diagnostic testing.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CASSVILLE HEALTH CARE CENTER in CASSVILLE, MO was cited for violations during a health inspection on September 10, 2025.
The incident began October 24, 2025, when LPN F found the bruise during routine care.
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.