LPN F had been working at Cassville Health Care Center since August or October 2024 without any of the required screening. LPN G was observed by inspectors working as the charge nurse on September 8 at 7:47 PM, also without proper vetting.
Neither nurse had undergone criminal background checks, been screened through the state's Family Care Safety Registry, or had their nursing licenses verified before starting work. The facility also failed to check the Employee Disqualification List, which tracks workers banned from caring for vulnerable populations.
"The facility staff did not conduct a CBA, Family Care Safety Registry, NA Registry, or EDL check and did not check his/her nursing license prior to him/her starting his/her shift," inspectors wrote.
The Business Office Manager confirmed during a September 9 interview that the facility had no personnel files for either LPN F or LPN G. The manager acknowledged not conducting any of the required background screenings before allowing the nurses to work.
LPN F worked the previous night alongside a certified nursing assistant and nurse aide, despite having no employment application on file and receiving no orientation or education before the shift.
The facility's own staff recognized the dangers of this practice.
LPN D told inspectors that new employees were required to complete onboarding, orientation, and appropriate background checks before working. "Nurses should not be allowed to work the floor prior to checking their license because the facility would not know if they had a valid nurses license that was unencumbered, and this would not be safe for the residents," the nurse said.
Certified Medication Technician J echoed these concerns, stating that background checks, registry screenings, and license verification should be completed upon hire. "No one should have access to the residents prior to these being completed and he/she did not believe they could work on the floor before these were completed."
The facility's Medical Director maintained that even in emergency staffing situations, administrators should verify nursing licenses, check the Employee Disqualification List, and perform criminal background checks.
Yet the Administrator admitted during two separate interviews that none of these basic safety measures had been followed for either nurse.
"The facility did not conduct a CBC, FCSR, NA Registry, or EDL checks and did not check the status of their nursing licenses prior to the LPNs starting their shifts," the Administrator told inspectors.
The Administrator said he didn't know if either nurse had completed employment applications and couldn't identify who had authorized them to work shifts.
The violations put residents at risk of receiving care from nurses whose licenses might have been suspended, revoked, or encumbered by disciplinary actions. Without criminal background checks, the facility had no way of knowing whether the nurses had been convicted of crimes that would disqualify them from working with vulnerable populations.
The Employee Disqualification List specifically tracks healthcare workers who have been banned from providing care due to abuse, neglect, or other serious violations. By failing to check this registry, Cassville Health Care Center potentially allowed nurses with documented histories of harming patients to provide direct care.
The Family Care Safety Registry serves as another critical safeguard, maintaining records of substantiated abuse and neglect findings against healthcare workers. The facility's failure to screen both nurses through this system left residents exposed to potential harm from workers with documented histories of misconduct.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" to many residents. The finding stemmed from a complaint investigation completed September 10, 2025.
The case illustrates how basic hiring failures can compromise resident safety at nursing facilities. While both nurses held valid LPN licenses at the time of the inspection, the facility had no way of verifying their credentials or ensuring they were legally permitted to provide patient care when they began working months earlier.
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.