Cassville Health Care Center: Pain Medication Denied - MO
The resident, whose name was not included in the inspection report, was known to take tramadol before dialysis. On the morning of September 10, 2025, he asked for it. His pain was rated at an 8 out of 10. LPN H, the nurse on duty, knew about the tramadol order. She also knew she didn't have access to the medication dispensing machine to pull it.
She did not call the physician. She did not send the resident to the hospital. She did not escalate it.
What she gave him instead was nothing. A CMT, a medication technician with more limited authority, eventually gave the resident acetaminophen — two regular-strength tablets — because that was all the technician could access. The MAR shows that happened at 10:51 a.m.
The resident was still waiting for his tramadol hours later. When inspectors observed him at 12:13 p.m., he told the CMT his pain was still an 8 out of 10. He said he hadn't gotten his medication on September 9th either. He was tired of asking.
"He/she did not get his/her medicine on 09/09/25, as well as hasn't received it today and he/she was tired of asking for it," the inspection report states.
The tramadol was finally administered at 12:32 p.m., after a different nurse, LPN I, came out of the medication room and gave it to him. The MAR records the time as 12:22 p.m.
LPN H, interviewed the same morning, acknowledged she had known before her shift began that she lacked access to the dispensing machine. She said a CMT had pulled some medications for her in advance, but that without those pre-pulled doses, she couldn't give PRN medications at all. She said she was aware the resident typically received pain medication before dialysis. She said she considered an 8 out of 10 to be severe pain. And then she said she hadn't felt the resident was in enough pain to send him to the hospital or call the doctor.
The charge nurse, interviewed at 10:00 a.m., said he or she had reached out to the administrator about the access problem at 8:59 that morning and had not heard back. The charge nurse said a nurse without dispensing access should call the Director of Nursing or the administrator. The charge nurse also said pain rated at an 8 out of 10 is severe.
The Medical Director said he expected nurses to have access to the machine before their shifts started. He said a resident requesting a PRN pain medication should receive it per orders. That's what the orders said. That didn't happen.
The administrator, reached by inspectors that afternoon, said he was not aware residents had not been receiving their medication. He said he was not familiar with the medication dispensing system but acknowledged access should have been set up before nurses started their shifts. He said if a nurse couldn't do her job, she should have contacted him.
The charge nurse had contacted him. At 8:59 a.m. He had not responded.
CMS classified the violation as causing actual harm to residents. The inspection was conducted as a complaint investigation.
The resident had been asking for two days. On the morning inspectors arrived, he was still asking. He got the tramadol at 12:32 p.m., after more than a day without it, after telling staff repeatedly that he was in severe pain, after an inspector watched him explain to a medication technician that he was exhausted from asking.
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, whose name was not included in the inspection report, was known to take tramadol before dialysis.
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.