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F0610
J

Failure to Protect Resident During Investigation of Staff Misappropriation

Cassville, Missouri Survey Completed on 09-10-2025

Penalty

Fine: $15,375
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from potential abuse, neglect, exploitation, or mistreatment during an ongoing investigation of misappropriation involving a registered nurse (RN). Despite the facility's policy requiring immediate suspension and removal of any staff member accused of mistreatment pending investigation, the RN under investigation for both diversion of narcotics and misappropriation of resident funds was allowed to return to work as the only nurse on duty. This action was taken after the facility owner personally contacted the RN and requested their return, despite the ongoing investigation and the RN's prior termination for substantiated allegations. A resident with chronic obstructive pulmonary disorder, congestive heart failure, and an irregular heartbeat, who was cognitively intact, reported that the RN had solicited and received money from them on multiple occasions, both in cash and through a mobile payment app. The resident also reported that the RN's child broke their tablet. The resident only felt safe to report the financial exploitation after the RN was initially suspended. However, when the RN returned to the facility, the resident experienced significant fear and mental anguish, packed their belongings, and considered leaving the facility due to fear of retaliation. The RN attempted to contact and speak with the resident after returning to work, further exacerbating the resident's distress. Multiple staff members, including nurses and certified nurse aides, expressed concern and stated that the RN should not have been allowed to return to the facility while under investigation. Staff interviews confirmed that the RN was the only nurse on duty during their return and that the resident was visibly upset and fearful. The facility's own policies and staff statements indicated that accused employees should be suspended and removed from resident care areas pending investigation, but these procedures were not followed, resulting in the resident not being protected from further potential harm.

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