Cassville Health Care Center: Nurse Forged Narcotic Records - MO
The resident had an order for hydrocodone/acetaminophen, but the order was never entered into the electronic medical record. That meant there was no documented history of the medication ever existing, no record of it being administered, and no paper trail when doses kept coming out of the dispensing machine anyway.
RN A told inspectors she had pulled the medications from the dispensing system because they were the wrong order, and that she intended to destroy them. She said she communicated with the pharmacy and the resident's physician about the discrepancies. She had no documentation of any of it. No progress notes. No follow-up. Nothing.
She also said she had not used a destruction log since July 2025.
That is a period of roughly six weeks during which narcotics were dispensed, removed, and apparently destroyed with no written record of what was taken or when. There is no way to account for what happened to those medications.
LPN D told inspectors a different story entirely. He or she said RN A never gave a clear answer about why the medications kept being dispensed, only that she would be destroying them and would take them to her office. LPN D did not know whether RN A kept them in a locked box. More significantly, LPN D said RN A forged his or her signature on the narcotic sheets, claiming the two of them had destroyed medications together. LPN D was not in the building on the dates RN A listed.
Narcotic destruction at the facility required two nurses to be present and to sign off together. RN A told inspectors she had destroyed the narcotics with LPN D. LPN D said that never happened.
LPN C, who was working on September 3, 2025, discovered the discrepancies and found no destruction record for the medications that had been dispensed. LPN C told inspectors that RN A had never asked him or her to witness any destruction.
The resident, who was nearing the end of life, did not receive the pain medication that had been ordered. LPN D told inspectors that toward the end of the resident's life, the resident did begin experiencing pain, and a new order for PRN hydrocodone/acetaminophen 5-325 mg every four hours as needed was obtained on September 4, 2025, the day before RN A was fired.
The former administrator told inspectors that RN A was placed on suspension pending investigation and terminated on September 5 after what he described as an overwhelming amount of evidence against her for misappropriation of narcotics and resident funds. The investigation had not been completed when inspectors arrived.
Eight separate complaints were filed with the state, all tied to the same events at the same facility.
The inspection report categorized the violation as causing minimal harm or potential for actual harm. That classification sits alongside the fact that a resident in the final days of life went without documented pain management while a nurse was apparently diverting the medication that had been ordered for that purpose, signing a coworker's name to records to conceal it, and taking the drugs to her office.
What the resident experienced in those final days, and whether the pain order obtained on September 4 was ever filled before she was gone, the inspection report does not say.
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 resident had an order for hydrocodone/acetaminophen, but the order was never entered into the electronic medical record.
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.