Cassville Health Care Center

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

from the medication dispensing system as it was the wrong order. They did not. So, she pulled them out to destroy;-The resident had an order, it was just not transcribed into the EMR, so there is no record of it ever existing and/or being administered;-The resident never took pain medication;-She did communicate with the pharmacy and Physician, but has no record of it. She did not document any of the concerns in the resident's progress notes;-She destroyed the narcotics with another nurse, LPN D;-She was not aware there was supposed to be a destruction log. She had not used a destruction log since July 2025, so there is no way of telling what medications were destroyed or not;-She was not sure why the medication kept being dispensed, she called the pharmacy to get this corrected, but did not document it or follow up.During an

interview on 09/08/25, at 1:11 P.M., LPN C said the following:-He/she was on shift at work on 09/03/25, and discovered several discrepancies for the resident's narcotics;-The resident did not have an order for the medication that was being dispensed by RN A, and he/she could not find a destruction record for all the medications that had been dispensed;-RN A never asked him/her to destroy any medications with her.-The way the medication dispensing system worked was the nurse on shift had to load a roll of blank packets into the machine. The nurse must enter in the resident name and select which medication they are wanting dispensed. After they are dispensed you either put them in a locked box in the medication cart and log them and/or administer them to the resident;-There are supposed to be two nurses for destruction of narcotics.During an interview on 09/09/25, at 12:00 P.M., LPN D said the following:-There was no log for the destruction of the resident's narcotics that were pulled from the medication dispensing system;-He/she asked RN A why those medications were being dispensed and never got a clear answer other than RN A would be destroying them and she would then take them to her office. He/she was unaware if RN A kept them in a locked box or not;-He/she came to learn the resident did have an order for hydrocodone/acetaminophen but it was never transcribed into the resident's EMR so it was never administered that he/she was aware of;-RN A forged his/her signature on the narcotic sheets. He/she was not in the building on the dates that RN A said that he/she destroyed narcotics with her;-Toward the resident's end of life, he/she did begin to experience pain, and he/she did obtain an order for PRN hydrocodone/acetaminophen 5-325 mg every four hours as needed, on 09/04/25. During an interview on 09/07/25, at 3:46 P.M., the Former Administrator said RN A was placed on suspension pending investigation and was terminated on 09/05/25 after seeing an overwhelming amount of evidence against her for misappropriation of narcotics and resident funds.Complaints #2608924, #2609968, #2609971, #2609989, #2609995, #2610122, #2610146, and #2610229

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

since August or October 2024;-The facility staff did not conduct a CBA, Family Care Safety Registry (FCSR - a registry the includes EDL and CBC checks), NA Registry, or EDL check and did not check his/her nursing license prior to him/her starting his/her shift;-He/she did not fill out an application for employment and did not do any orientation or education prior to working his/her shift;-He/she worked last night with a certified nursing assistant (CNA) and a nurse aide (NA);.-The LPN was observed working as the charge nurse.Observation on 09/08/25, at 7:47 PM., showed LPN G working as the charge nurse.During an

interview on 09/09/25, at 8:50 A.M., the Business Office Manager (BOM) said the following:-He/she did not have personnel files for LPN F or LPN G;-He/she did not conduct a CBC, EDL, FCSR, or NA Registry on

the LPNs prior to the LPNs working the floor.During an interview on 09/09/25, at 12:10 P.M., LPN D said

the following:-New staff were required to complete onboarding, orientation, and the appropriate background and licensure checks prior to working a shift;-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.During an interview on 09/10/25, at 11:58 A.M., Certified Medication Technician (CMT) J said the following:-Upon hire, the facility completed background checks, NA registry, and checked the potential employees license;-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.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said in the case of emergency staffing, he/she still expected the facility staff to check the status of the nurses' license, check

the EDL list, and perform a CBC.During interviews on 09/09/25, at 10:50 A.M., and on 09/10/25, at 3:36 P.M., the Administrator said the following:-When the facility hired staff they conducted a NA registry, EDL, CBC, FCSR checks, and confirmed nurses' licenses;-He/she did not know if LPN F or LPN G completed applications for employment prior to starting their shifts;-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;-He/she did not set the LPNs up to work their shifts and did not know who did this.Complaint #2611677

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

extra tablets to be dispensed;-RN A provided controlled substance destruction logs, but the Former Administrator noted that RN A scribbled on the paper prior to handing it to him/her;-There were still at least 26 hydrocodone/acetaminophen tablets that were unaccounted for at this time in the investigation;-RN A was suspended pending investigation.Review of DHSS records showed the facility did not self-report related to the misappropriation of medications.During an interview on 09/09/25, at 2:10 P.M., the former Administrator said the following:-He/she reported the allegation of misappropriation of narcotics to the RNC and the RDO and they felt the allegation was not reportable, so they did not report to DHSS.During an

interview on 09/08/25, at 7:12 P.M., LPN E said if he/she received a report of misappropriation, he/she reported to the Administrator immediately. The Administrator reported to DHSS within two hours.During an

interview on 09/09/25, at 12:10 P.M., LPN D said the following:-If a certified nurse aide (CNA) or certified medication technician (CMT) received an allegation of misappropriation, they reported to their charge nurse immediately and the charge nurse reported to the DON, Social Services Designee (SSD), or Administrator immediately;-Any staff member can report to DHSS, but usually the DON, SSD, or Administrator reported to DHSS within two hours.During an interview on 09/09/25, at 2:49 P.M., CNA M said if he/she received an allegation of misappropriation, he/she reported to the charge nurse immediately. The Administrator reported to DHSS within two hours.During an interview on 09/10/25, at 8:46 A.M., CNA L said if he/she received an allegation of misappropriation, he/she reported to the charge nurse immediately. If the allegation was against the charge nurse or the DON, he/she reported to the Administrator. The Administrator reported to DHSS within two hours.During an interview on 09/10/25, at 11:58 A.M., CMT J said if he/she received a report of misappropriation, he/she reported to the charge nurse immediately and then followed up with the Administrator to ensure it was reported to them. The Administrator reported to DHSS within two hours.During an interview on 09/10/25, at 3:36 P.M., the Administrator said he/she reported any allegations of misappropriation to DHSS immediately.Complaint #2608924, #2609968, #2609971, #2609989, #2609995, #2610122, #2610146, and #2610229.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

told the SSD that RN A called the resident;-The SSD told the resident to not tell the RN where the resident was;-The resident said he/she was fine, but it scared him/her when the RN called.During an interview on 09/08/25, at 3:05 P.M., Resident #4 said the following:-RN A should not be in the facility;-He/she was worried RN A could steal money from residents and was worried about the safety of the residents.During

an interview on 09/08/25, at 10:06 A.M., Housekeeper (HK) U said the following:-If a staff member was accused of misappropriation they were suspended pending the investigation;-If the investigation showed

the allegation to be substantiated, the staff member would not be allowed to come back to work;-When he/she arrived at the facility this morning (09/08/25), he/she saw RN A, who was an alleged perpetrator in

an investigation in the building working.During an interview on 09/08/25, at 10:48 A.M., CNA P said when he/she arrived at work on 09/08/25, at 5:50 A.M., RN A was working. RN A was under investigation for misappropriation.During an interview on 09/10/25, at 11:58 A.M., Certified Medication Technician (CMT) J said he/she spoke with the resident and the resident was very upset that RN A was in the facility.During an

interview on 09/08/25, at 10:55 A.M., CNA Q said the following:-When he/she arrived at work on 09/08/25, at 5:45 A.M., RN A and another CNA were the only staff that worked overnights;-The RN was under investigation for misappropriation of money from Resident #1. During an interview on 09/08/25, at 11:00 A.M., CNA L said when he/she arrived at work on 09/08/25, at 5:45 A.M., RN A was working in the facility.During an interview on 09/08/25, at 11:06 A.M., CNA S said when he/she arrived at work on 09/08/25, at 6:00 A.M., RN A was the nurse.During an interview on 09/09/25, at 2:49 P.M., CNA M said if

an employee was accused of misappropriation, they should be suspended pending investigation not allowed to be in the facility.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said he/she would not expect a staff member under investigation to be brought back to the facility unsupervised and the staff member should not have access to the resident.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-If a staff member was accused of misappropriation, they were suspended pending an investigation;-The staff member should not have access to the resident;-Resident #1 was not protected when RN A was allowed back into the facility on [DATE REDACTED].Complaint #2608924, #2609968, #2609971, #2609989, #2609995, #2610122, #2610146, and #2610229NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J.

Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

determine a cause for the injury.-He/she notified the DON, and he/she said to document as an unwitnessed bruise of unknown origin on the risk assessment form.-The nurse said it was an odd place for a bruise.-The nurse said he/she texted the resident's physician to notify of the bruise but did not get a response.-The nurse did not receive an order for an ultrasound or x-ray.-The nurse put ice on the hematoma, and the swelling started to decrease in size.-The resident should be monitored every shift until the bruise resolved.

Residents Affected - Few

During an interview on 11/20/25 at 10:10 A.M., LPN B said the nurse should assess and monitor the resident, obtain vital signs, conduct a neurological assessment, and notify the DON, family, and physician for a change of condition. All information should be documented in a progress note.

During an interview on 11/25/25, at 9:58 A.M., LPN D the if he/she observed a large bruise on a resident, he/she would complete an incident report in the electronic medication record, notify the resident's physician, the DON and would report the bruise to the next shift nurse to monitor.

During interviews on 11/24/25 at 12:50 P.M. and on 11/25/25 at 1:32 P.M., the DON said the following:-LPN F reported the bruise to him/her on 10/24/25. -LPN F notified the physician and obtained any order to rule out a blood clot to the left leg.-He/she did not know what the delay in entering the order in for the x-ray and ultrasound. -The x-ray and ultrasound order originally was entered incorrectly, and the lab technician brought the wrong equipment on 10/27/25 and had to reschedule the visit.-The resident had a multicolored bruise to the left inner leg that was smaller than a softball, but larger than an apple.-Since the resident complained of pain with movement of the leg and walking, the DON suspected a blood clot.-The resident required stand by assistance with showers but was independent with all other cares.-There was no indication the resident had a fall.-He/she does not know why the nurse documented the resident had a fall.-The nurse should have completed a skin assessment upon discovery of the bruise on 10/24/25.-The bruise should have been monitored every shift until it resolved. -The nurse should document notification to

the physician regarding ultrasound and x-ray results.

During an interview on 11/25/25 at 11:34 A.M., the ultrasound company representative said the following:-There were no notes showing a technician brought the wrong equipment and had to reschedule

the appointment.-The only order for the resident was on 10/27/25 for an x-ray and ultrasound.-The only visit recorded for the resident was on 10/28/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

narcotics;-He/she does not believe that LPN H has access either;-If a nurse did not have access, they should call the Director of Nursing (DON), or the Administrator;-He/she did reach out to the Administrator but had not heard back. He/she contacted him around 8:59 A.M.,-Residents should receive their medication per physician's order;-If a nurse does not have access and cannot administer medication, he/she would send the resident out to the hospital for pain control;-He/she would consider pain rated as an 8 out of 10 as severe pain.During an interview on 09/10/25, at 10:11 A.M., LPN H said the following:-He/she had medications pulled for him/her by the CMT that he/she could have given them. He/she did not have access to the medication dispensing machine so if they did not have those pulled for him/her, he/she would not have been able to give PRNs;-He/she should have had access to it before he/she started his/her shift;-He/she did not recall if the resident asked him/her for any pain medication. He/she was aware that the resident usually got a pain medication before dialysis but he/she was unable to administer it due to not having access;-He/she considered pain rated as 8 out of 10 to be severe pain;-He/she could have reached out to the physician or sent the resident to the hospital, but did not feel the resident was in enough pain to warrant that. Review of the resident's September 2025 MAR showed on 09/10/25, staff documented administering acetaminophen 325 mg two tablets at 10:51 A.M.During an interview on 09/10/25, at 11:58 A.M., CMT J said the following:-The resident did complain of pain to the charge nurse this morning. The resident asked the CMT to look at the resident's PRN tramadol;-The CMT had access to give the resident acetaminophen so that is what he/she did;-He/she did not have access to the medication dispensing machine to pull the resident's tramadol;-Pain should be addressed immediately. Observation and interview

on 09/10/25, at 12:13 P.M., showed the resident speaking with CMT J. The CMT told the resident he/she would check with the nurse regarding his/her tramadol. The resident reported his/her pain level to be rated at an 8 out of 10. 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;-LPN I came out of the medication room and administered the tramadol at 12:32 P.M.Review of the resident's September 2025 MAR showed on 09/10/25, staff documented administration of tramadol 50 mg tablet at 12:22 P.M.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said the following:-He expected nurses to have access to the medication dispensing machine prior to starting their shift;-If a resident requested a PRN pain medication, they should receive it per orders. During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He was not aware residents were not receiving their medication;-He was not familiar with the medication dispensing system, but access should have been provided to the nurses prior to starting their shifts. If the nurses did not have access or the ability to perform their jobs, they should have contacted him.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was unable to due to a sick family member. He/she was scheduled to come in nights on 09/08/25, but already called in.During an interview on 09/10/25, at 11:58 A.M., CMT J said the following:-When he/she first started at the facility six months ago they had a schedule but after the staff member who was doing the schedule quit, they have not had one since;-Recently, he/she had not seen a schedule or a nursing staffing sheet;-The facility had a shortage of nurses and some nurses have worked for thirty plus hours.During an

interview on 09/09/25, at 4:33 P.M., the Facility Physician said he/she was not aware that only two staff were left in the building overnight on 09/08/25. Two staff was not enough to care for the residents.During interviews on 09/10/25, at 11:04 A.M., and on 09/11/25, at 3:56 P.M., the Medical Director said the following:-He/she did not know the staffing requirements for 44 residents, but did not believe one nurse and one CNA was sufficient. He/she believed one more staff member added to this would be sufficient, but this depended on the level of care the residents' required;-Having only one staff in the building was not appropriate;-He/she was not aware that no staff was in the building on 09/08/25 for a short amount of time;-He/she expected the facility to have a schedule and a working staffing sheet.During an interview on 09/09/25, at 10:50 A.M., the Administrator said the following:-The facility was actively recruiting staff for nursing;-The facility had a contract with a staffing agency but they were not going to use the agency unless

they had an emergency with staffing. He/she did not feel the facility had a staffing emergency at the time.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He/she was getting nurse staffing covered, but the facility did not have enough staff, so he/she was bringing staff from other facilities to assist;-Two staff was not enough to care for the residents at night;-It was not appropriate for the RN to send the CNA for a drink during the night leaving only one staff in the building and the RN should have stayed in the facility;-He/she had worked on a schedule since he/she arrived on 09/08/25 and all the staff were instructed to get with the Regional Nurse Consultant (RNC) about their schedules.Complaint #2598186, #2609971, #2609968, #2609989, #2609995, #2610146, #2610182, and #2610229

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732

Post nurse staffing information every day.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to post the current daily nurse staffing information in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility census was 44.Review of the facility's policy titled Nurse Staffing Posting Information Policy, revised 06/26/24, showed the following:-It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time;-The Nurse Staffing Sheet will be posted on a daily basis and will contain facility name; the current date; facility's current census; the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift;-The facility will post the Nurse Staffing Sheet at the beginning of each shift;-The information posted will be presented in a clear and readable format and in a prominent place readily accessible to residents and visitors;-A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. The information shall reflect staff absences on that shift due to callouts and illness. Staffing shall include all nursing staff who are paid by the facility (including contract staff). Any staff not paid for by the facility, such as hospice staff or individuals hired by families, shall not be included;-Nursing schedules and posting information will be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater;-The facility will, upon oral or written request, make the nurse staffing data available to

the public for review at a cost not to exceed the community standard.1. Observations on 09/08/25, at 11:03 A.M. and 4:41 P.M., 09/09/25, at 9:03 A.M., and 09/10/25, at 12:27 P.M., showed staff did not have the Nurse Staffing Posting displayed in the entry hall, at the nurses' station, or by the time clock.During an

interview on 09/08/25, at 11:06 A.M., Certified Nursing Assistant (CNA) S said he/she did not know where

the Nurse Staffing Sheet was posted, but thought it should be posted.During an interview on 09/08/25, at 11:52 A.M., Registered Nurse (RN) A said the following:-The Nurse Staffing Sheet should be posted behind

the nurses' station under the white board on the wall visible to anyone that came to the facility;-The Director of Nursing (DON) was responsible for the Nurse Staffing Sheet;-He/she did not know the last time it was posted, and the sheet was not posted today;-He/she was the former DON and was responsible for posting

the Nurse Staffing Sheet, but had not posted it for at least four months.During an interview on 09/08/25, at 1:03 P.M., Licensed Practical Nurse (LPN) C said the following:-The Nurse Staffing Sheet should be posted daily;-He/she had not seen the Nurse Staffing Sheet posted and did not know where the DON posted it;-RN

A (the former DON) was responsible for posting it.During an interview on 09/08/25, at 7:12 P.M., LPN E said the following:-He/she had not seen the Nurse Staffing Sheet in at least three months; -RN A (the former DON) filled the Nurse Staffing Sheet out and posted it.During an interview on 09/09/25, at 12:10 P.M., LPN D said the following:-He/she had not seen the Nurse Staffing Sheet posted in a long time;-The night nurse was responsible for filling out the Nurse Staffing Sheet.During an interview on 09/10/25, at 12:00 P.M., the Business Office Manager said the facility had not completed the Nurse Staffing Sheet in a long time, so he/she was unable to provide any copies.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the Nurse Staffing Sheet should be posted daily.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9:00 A.M. for shortness of breath; -On 11/02/25, 11/03/25, 11/05/25, 11/07/25, 11/09/25, 11/10/25, 11/12/25, 11/13/25, 11/15/25, 11/16/25, 11/17/25, 11/18/25, and 11/19/25 staff documented administering

the Trelegy at 7:00 A.M. and 9:00 A.M.During an interview on 11/19/25 at 12:27 P.M., the resident said at times staff did not administer his/her medicine as ordered.During an interview on 11/19/25 at 10:55 A.M., Licensed Practical Nurse (LPN) A said the following:-He/she had observed some duplication of orders on

the medication administration record;-He/she spoke to the Director of Nursing (DON) about the issue recently (unsure what day). During an interview on 11/19/25 at 11:00 A.M., LPN B said he/she observed some duplicate physician orders for medications and tried to discontinue the extra order when he/she found

the errors. During an interview on 11/24/25 at 9:38 A.M., Certified Medication Technician (CMT) E said the following:-The facility had an issue with some of the medications appearing twice on resident MARs;-He/she was unsure why the resident had two separate Trelegy orders;-The CMT said he/she gave

the resident Trelegy and then if the resident needed the medication for shortness of breath, he she would give the resident a second dose at 9:00 A.M. During an interview on 11/24/25 at 11:03 A.M., the DON said

the following:-Staff should be giving the resident Trelegy one puff (inhalation) every day, per the current order dated 10/06/25;-The resident's MAR contained a duplicate Trelegy order. Nursing staff should not have administered a second inhalation of Trelegy per day;-During medication pass, the CMT or nurse administering the medication should have realized the Trelegy duplicate order and documented not administered on the second order, and then he/she should have notified the nurse on duty of the duplicate order;-The nurse on duty should have then discontinued the duplicate order from the MAR. During an

interview on 11/25/25, at 4:10 P.M., the Administrator said nursing should verify the order/MAR matched

the prescription on the medication before administering the medication. Complaint 2659592

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

1. 2. Review of Resident #10's face sheet showed the following information:-Diagnoses including CHF and

orthostatic hypotension (a condition where blood pressure drops significantly and suddenly when changing positions).

Review of the resident's quarterly MDS, dated [DATE REDACTED], showed the following: -Cognitively intact.-Diagnoses including CHF and orthostatic hypotension.

Review of the resident's current November 2025 Physician Orders showed an order, dated 03/05/25, for Entresto (heart failure medication) tablet 24-26 mg, give one tablet by mouth two times a day for CHF. Hold if SBP was less than 100 mm/Hg.

Review of the resident's November 2025 MAR showed the following: -An order, dated 03/05/25, for Entresto tablet 24-26 mg, give one tablet by mouth two times a day for CHF. Hold if standing blood pressure (SBP) was less than 100 mm/Hg.-Staff administered the resident's Entresto medication without checking the resident's blood pressure from 11/01/25 through 11/19/25, twice daily at 7:00 A.M. and 3:00 P.M., except on 11/05/25 and 11/18/25 at 7:00 A.M. due to resident's refusal of medication.

Review of the resident's vital sign summary for November 2025 showed staff documented the resident's blood pressure was taken one time on 11/11/25.

During an interview on 11/24/25, at 12:40 P.M., Certified Medication Technician (CMT) E said the following:-The resident did not need his/her blood pressure checked prior to administering his/her medications.-He/she did not know what the resident's blood pressure that morning was prior to administering his/her medication.

2. 3. During an interview on 11/24/25 at 12:40 P.M., CMT E said the following:-If a medication required a blood

pressure or pulse to be taken it would be indicated on the MAR.-The blood pressure or pulse should be checked prior to medication administration to make sure it was within the ordered parameters.-There was no place to document residents' blood pressure on the MAR.

During an interview on 11/25/25 at 1:47 P.M., Licensed Practical Nurse (LPN) F said a resident's blood pressure and pulse should be checked prior to administering medication if there are parameters. The vital signs should be documenter on the MAR.

During an interview on 11/24/25 at 12:50 P.M., the Director of Nursing said staff should check the resident's blood pressure or pulse if it was indicated on the MAR. There should be a spot to document vital signs on

the MAR.

During an interview on 11/25/25 at 4:10 P.M., the Administrator said blood pressure and pulse should be listed in the MAR if indicated. Staff should follow physician orders, including any parameters ordered, when administering medication.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

records (EMR); -He/she was unable to give the residents their insulin. He/she believed around 11 residents went without their insulin due him/her having a broken hand and not being able to administer. The facility was aware of this when they asked him/her to work; -He/she typically does not work at the facility and was not provided any access for the EMR system and/or the medication dispensing system;During an interview

on 09/09/25, at 4:33 P.M., the facility physician said the following:-He/she would expect nurses to have access to the medication dispensing system prior to starting their shifts;-He/she has not been made aware of any missed medication administrations;-If a resident's order says to notify her regarding blood sugar levels, she expected to be notified.During an interview on 09/10/25, at 9:49 A.M., LPN I said the following:-If

a nurse did not have access to the EMR or medication administration system they should call the Director of Nursing (DON), or the Administrator;-Residents should receive their medication per physician's order;During an interview on 09/10/25, at 11:04 A.M., the Medical Director said the following:-He expected nurses to have access to the medication dispensing system prior to starting their shift;-If a resident has an order for insulin, he expected them to receive it.During an interview on 09/10/25, at 11:58 A.M., Certified Medication Technician J said the following:-LPN F did not have any access to the resident's records;-LPN F made several calls in attempts to get access and the ability to pass resident medications; -If a resident had

an order for medication, they should be receiving that medication.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He was not aware residents were not receiving their medication;-He was not familiar with the medication dispensing system, but access should have been provided to the nurses prior to starting their shifts. If the nurses did not have access or the ability to perform their jobs, they should have contacted him.Complaints #2598186, #2609971, #2611677

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

the E level.Complaints #2610146, #2610182, and #2611677

Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

09/09/25, at 12:10 P.M., Licensed Practical Nurse (LPN) D said the following:-Staff were required to have a chauffer's license to operate the facility's van;-He/she saw the Transport Driver take residents to appointments recently;-He/she did not know if the driver had a valid driver's license.During an interview on 09/10/25, at 11:04 A.M., the Medical Director said he/she would not expect anyone with a suspended license to drive or be the transport driver for the facility.During an interview on 09/10/25, at 3:36 P.M., the Administrator said the following:-He/she understood that when the Transport Driver was hired, the driver's license was not suspended;-When the BOM found out the driver's license was suspended, the BOM told

the driver they could not drive the van.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, facility staff failed to fully implement their infection control program when staff failed to ensure the required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely as per policy for two staff (Licensed Practical Nurse (LPN) F and LPN G) of two staff sampled. The facility census was 44. Review of the facility's policy titled Tuberculosis Testing, revised 06/29/23, showed the following:-The purpose of the policy was to ensure each resident and employee of the facility is tested for tuberculosis (TB) after entering the facility to prevent the spread of infection;-Upon hire, a new employee will receive a two-step PPD skin test (a test used to determine exposure to TB);-Each employee will also have an annual one-step TB test to ensure that any possible infections can be triggered proactively to prevent further spread;-All TB tests will be kept on file in the according areas (employee files).1. Reviewed showed the facility did not provide personnel files for LPN F and LPN G upon request. Observation on 09/08/25, at 7:46 P.M., showed LPN G was working as the charge nurse.During an observation and

interview on 09/09/25, at 9:09 A.M., LPN F said the following:-He/she was not currently employed by the facility. He/she used to work for the facility but left in August or October 2024;-He/she worked the floor last night with a certified nursing assistant (CNA) and a nurse aide (NA);-He/she did not have a TB test prior to working on the floor with the residents.-The LPN was working as the charge nurse.During an interview on 09/09/25, at 8:50 A.M., the Business Office Manager (BOM) said the following:-He/she did not have personnel files for LPN F and LPN G;-LPN F and LPN G were not employees of the corporation and were not employees of a staffing agency;-He/she did not have TB tests for the LPNs.During an interview on 09/09/24, at 12:10 P.M., LPN D said staff should have a negative TB test prior to working the floor and if

they did not, this was not safe for the residents. During an interview on 09/09/25, at 4:33 P.M., the facility physician said staff should have a negative TB test prior to working with the residents. During an interview

on 09/10/25, at 11:04 A.M., the Medical Director said staff should have a negative TB test prior to working

the floor but in the case of emergency staffing needs, he believed if the staff wore a mask that would be sufficient to protect the residents.During interviews on 09/09/25, at 11:02 A.M. and 09/10/25, at 3:36 P.M.,

the Administrator said the following:-Upon hire, staff should have their first TB skin test read prior to working

on the floor;-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;-LPN F and LPN G did not have a negative TB test prior to working the floor.Complaint #2611677

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919

Complaint 2675693

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cassville Health Care Center

1300 County Farm Road Cassville, MO 65625

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm

reported seeing mice a few times in the last couple weeks in his/her room;-He/she thought the facility put traps out for the mice, but did not think the traps were working to catch the mice. During an interview on 11/19/25 at 10:47 A.M., Housekeeper (HK) J the following:-He/she observed mice on the back resident halls;-Last week, he/she saw a mouse run across the hall into resident room [ROOM NUMBER];-He/she documented the mouse observation in the exterminator's logbook.

Residents Affected - Some

During an interview on 11/25/25 at 11:35 A.M., HK K said the following:-He/she changed positions from maintenance assistant to housekeeper in the early part of October 2025;-He/she had not seen any mice, but the residents had reported seeing a few mice. During interviews on 11/25/25 at 12:00 P.M., Certified Nurse Assistants (CNA) H and CNA I said the following:-The CNAs began working in the facility in August 2025 and both worked the night shift 6:00 P.M. to 6:00 A.M. Both aides said they saw one to two mice every night in the facility;-The CNAs said they have seen mice droppings in Resident #9's room;-Mice were frequently seen on the back hall near Resident #2's room and Resident #3's room.

During an interview on 11/25/25 at 12:30 P.M., CNA N said he/she witnessed a mouse running in the hallway on Friday. He/she had seen mice in the back hall rooms on more than one occasion.

During an interview on 11/25/25 at 12:50 P.M., CNA M said he/she saw mice on the back hall all the time.

Several residents had complained about seeing mice in the rooms. During an interview on 11/25/25 at 12:40 P.M., Certified Medication Technician (CMT) C said the following the facility had a pest log for staff documentation of pest sightings. The log was a blue binder from the pest company and was kept in a file cabinet behind the nurses' station. He/she said they wrote pest issues in the binder and that was the end of their part.

During an interview on 11/25/25, at 1:10 P.M., the Activity Director said the following:-He/she saw a mouse running down the hall last month, but had not seen one for a few weeks.

Observation on 11/25/25 at 1:10 P.M., of the activity area showed the following: -This surveyor observed the library/activity area at the end of the back hall (located on the northwest wing) of the facility;-The surveyor opened a lower cabinet containing boxes of jigsaw puzzles for resident use. Mouse droppings (approximately 20) were visible along the front edge of the cabinet;-The surveyor opened a drawer containing boxes of playing cards for resident use. The drawer contained mouse droppings.

During an interview on 11/25/25 at 1:32 P.M., the Director of Nursing said the following:-One of the night shift staff reported seeing mouse droppings one to two days ago and he/she notified the Administrator;-He/she had not observed any mice. During an interview on 11/25/25 at 1:54 P.M., Pest Control Service Technician L said the following:-He/She serviced the facility for pest control monthly;-He/She only provided rodent control measures for the exterior of the facility;-He/She completed monthly pest service on 11/18/25 and noted heavier activity at the exterior rodent traps;-He/She was unaware of any reports of rodents inside the facility until 11/25/25;-He/she was not aware of a logbook;-He/She was scheduled to return to the facility on [DATE REDACTED]. During an interview on 11/25/25 at 4:10 P.M., the Administrator said the following:-He/she was unsure if the pest control company reviewed the pest logbook located in the nurses' station;-He/she observed that the pest control company had not signed the logbook;-If staff observe or receive reports of pests in the facility, he/she would expect the staff to notify the Administrator, so that he/she could mention areas of concern to the pest control company. Complaint FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet