Cassville Health Care: Heart Medication Safety Failures - MO
Staff at Cassville Health Care Center gave Resident #10 Entresto tablets twice daily from November 1 through November 19, 2025, without monitoring blood pressure levels. The resident's physician had ordered the medication be held if systolic blood pressure dropped below 100 mm/Hg.
The resident suffers from congestive heart failure and orthostatic hypotension, a condition where blood pressure drops significantly when changing positions. Federal inspection records show staff documented taking the resident's blood pressure just once during the entire 19-day period — on November 11.
Certified Medication Technician E told inspectors on November 24 that the resident "did not need his/her blood pressure checked prior to administering his/her medications." The technician admitted not knowing what the resident's blood pressure was that morning before giving the medication.
The same technician acknowledged that blood pressure should be checked before giving medications when parameters are ordered. But the staff member said there was "no place to document residents' blood pressure on the MAR" — the medication administration record.
Licensed Practical Nurse F confirmed during a November 25 interview that vital signs should be checked and documented on the MAR before giving medications with parameters. The Director of Nursing agreed, telling inspectors there "should be a spot to document vital signs on the MAR."
The facility's administrator said staff should follow physician orders, including any parameters, when administering medication.
Entresto is prescribed specifically for heart failure patients like Resident #10. The medication can lower blood pressure, making monitoring crucial for patients who already have conditions affecting their blood pressure regulation.
The resident's medical records show cognitive function remained intact throughout the period, meaning they were aware of their care. Staff only skipped giving the medication twice during the 19-day span — both times because the resident refused it.
The physician's March 5 order was clear: give one Entresto tablet by mouth twice daily, but hold the dose if standing blood pressure falls below 100 mm/Hg. The same parameters appeared on the resident's medication administration record.
Despite having the hold parameters written directly on their medication records, staff administered the drug 36 times without a single blood pressure check, except for the isolated reading on November 11.
The violation affected multiple residents at the facility, according to federal inspection findings. Inspectors classified the deficiency as causing minimal harm or potential for actual harm.
Federal regulations require nursing homes to ensure residents receive medications according to physician orders and accepted standards of practice. The regulations specifically mandate that facilities follow any conditions or parameters set by prescribing physicians.
During interviews, nursing staff demonstrated they understood the requirement to check vital signs before giving medications with parameters. Yet the facility's medication administration records lacked space for documenting the required checks.
The disconnect between policy knowledge and actual practice left Resident #10 receiving a powerful heart medication without the safety monitoring their physician deemed necessary. For 19 days, staff made twice-daily decisions to give medication that could dangerously lower blood pressure in a resident already prone to blood pressure drops.
The resident's orthostatic hypotension meant their blood pressure could fall dramatically when standing or changing positions. Combined with a heart failure medication that can further reduce blood pressure, the lack of monitoring created conditions where the resident could have experienced dangerous blood pressure drops without staff knowledge.
Inspection records show no documentation of adverse effects during the period. But the resident went nearly three weeks receiving medication that their doctor specifically said should be held if their blood pressure dropped too low — with staff never checking to see if that threshold had been reached.
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 resident's physician had ordered the medication be held if systolic blood pressure dropped below 100 mm/Hg.
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.