Cassville Health Care: Unlicensed Nurses Work Floor - MO
LPN F worked as charge nurse on September 8, caring for residents despite having no TB test and unclear employment status. When confronted the next morning, the nurse told inspectors: "He/she did not have a TB test prior to working on the floor with the residents."
The nurse claimed to have left the facility months earlier, in August or October 2024, yet was observed working overnight with a certified nursing assistant and nurse aide.
Business Office Manager confirmed the facility had no personnel files for either LPN F or LPN G. "LPN F and LPN G were not employees of the corporation and were not employees of a staffing agency," the manager told inspectors. "He/she did not have TB tests for the LPNs."
The facility's own tuberculosis policy, revised in June 2023, requires all new employees receive a two-step tuberculosis skin test upon hire, before working with residents. The policy exists "to ensure each resident and employee of the facility is tested for tuberculosis after entering the facility to prevent the spread of infection."
Administrator admitted the breach during interviews on September 9 and 10. "Upon hire, staff should have their first TB skin test read prior to working on the floor," he told inspectors. But he couldn't explain how the nurses came to work there: "He did not know who had LPN F and LPN G come to the facility to work and did not know if they were employees of the corporation or a staffing company."
Both nurses lacked the negative TB test required before floor work, the administrator confirmed.
Other facility staff recognized the safety risk. LPN D told inspectors that staff without negative TB tests working the floor "was not safe for the residents." The facility physician agreed that staff needed negative TB tests before working with residents.
Only the Medical Director offered any justification for the lapse. While acknowledging staff should have negative TB tests before working the floor, he suggested that "in the case of emergency staffing needs, he believed if the staff wore a mask that would be sufficient to protect the residents."
The inspection found no evidence that masks were used as a protective measure for either nurse.
Tuberculosis remains a serious communicable disease affecting the lungs, characterized by fever, cough, and difficulty breathing. The facility's 44 residents were potentially exposed to an untested individual working as their charge nurse during overnight hours when medical supervision is typically minimal.
LPN G was observed working as charge nurse on September 8 at 7:46 PM. Like LPN F, this nurse had no personnel file at the facility and no documentation of required tuberculosis screening.
The facility's policy mandates annual TB testing for all employees to "ensure that any possible infections can be triggered proactively to prevent further spread." Records show neither nurse had any TB testing documentation on file.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" to residents, but noted that "many" residents were affected by the facility's failure to implement its infection control program.
The administrator's admission that he didn't know who had arranged for the nurses to work at his facility raises questions about the facility's hiring and credentialing processes beyond tuberculosis testing. Both nurses worked direct patient care roles without basic employment documentation.
LPN F's claim of having left the facility months earlier, combined with overnight charge nurse duties, suggests either confusion about employment status or unauthorized work arrangements that bypassed normal staffing protocols.
The violation stems from a complaint investigation, indicating concerns about infection control practices may have been raised by staff, residents, or families before the September inspection.
Cassville Health Care Center's failure to maintain basic employment records for nurses working resident care floors represents a fundamental breakdown in administrative oversight that extended well beyond the specific tuberculosis testing requirements.
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.
LPN F worked as charge nurse on September 8, caring for residents despite having no TB test and unclear employment status.
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.