Cassville Health Care Center: Double-Dose Inhaler Errors - MO
The inhaler was Trelegy, a combination drug used to treat chronic obstructive pulmonary disease and asthma. The resident's physician ordered one puff per day. What the medication administration record contained was two separate Trelegy orders, and staff administered both.
Records show staff documented giving the resident Trelegy at 7:00 a.m. and again at 9:00 a.m. on November 2, 3, 5, 7, 9, 10, 12, 13, 15, 16, 17, 18, and 19.
When inspectors interviewed the resident on November 19, the resident said staff sometimes didn't give the medication as ordered at all.
Two nurses had already noticed the problem before inspectors arrived. Licensed Practical Nurse A told inspectors she had seen duplicate orders on the medication administration record and had spoken to the Director of Nursing about it, though she couldn't remember what day that conversation happened. LPN B said she had also spotted duplicate physician orders for medications and had tried to discontinue the extra order when she found the errors.
Neither the duplicate order nor the double dosing had been resolved by the time inspectors conducted their interviews.
Certified Medication Technician E, who had been giving the resident the medication, told inspectors she was unsure why the resident had two separate Trelegy orders on the chart. Her explanation for the second dose: if the resident needed the medication for shortness of breath, she would give a second inhalation at 9:00 a.m. Trelegy is not a rescue inhaler. It is a once-daily maintenance medication.
The Director of Nursing, interviewed November 24, confirmed the resident's current order, dated October 6, called for one puff per day. She confirmed the MAR contained a duplicate order. She said the CMT or nurse administering the medication should have recognized the duplicate during the medication pass, documented it as not administered, and notified the nurse on duty. The nurse on duty should then have discontinued the duplicate order from the record.
None of that happened, across 13 documented days of double dosing.
The administrator, reached on November 25, said nursing staff should verify that the order and the medication administration record match the actual prescription before giving the medication.
The inspection was completed September 10, 2025, and filed as a complaint investigation. The deficiency was cited at a level of minimal harm or potential for actual harm.
What the record leaves open is how long the resident went without a dose on the days the medication wasn't given as ordered, and whether anyone connected those gaps to the same record-keeping failures that produced the double doses. The resident mentioned it. The chart didn't explain 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: 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 29, 2026 · Our methodology
CASSVILLE HEALTH CARE CENTER in CASSVILLE, MO was cited for violations during a health inspection on September 10, 2025.
The inhaler was Trelegy, a combination drug used to treat chronic obstructive pulmonary disease and asthma.
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.