F0725

E

Insufficient Nursing, Therapy Staffing, and Orientation Leading to Unmet Basic Care Needs

Kirkwood, Missouri Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on a 24-hour basis to meet residents’ basic care needs, as well as insufficient therapy staffing and inadequate orientation for new and agency staff. The facility’s own Facility Assessment, updated in December 2025, lacked completed data fields for residents’ assistance needs with activities of daily living such as bed mobility, transfers, bathing, eating, and toileting, despite stating that staffing assignments were based on census, acuity, and resident preferences. Observations showed residents with unmet hygiene needs: one resident was seen in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week, attributing this to not enough staff and requesting nail care. Another resident, incontinent of urine and dependent on staff for showers, was observed in stained clothing with frizzy, messy hair and reported being scheduled for showers twice weekly but wanting more frequent showers due to odor and visitors; documentation showed only three showers in January and no shower records for December.

Further observations showed another resident in bed on two separate days with toenails approximately 1/8 inch long and jagged and a whitish-yellow substance caked on the front teeth. This resident reported asking staff for nail trimming without assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA confirmed that nail care should be provided after showers and attributed the lack of oral hygiene assistance to staffing shortages, noting the resident required staff help with showers and personal hygiene. In addition to nursing care issues, review of therapy minutes from early September through late January showed no speech therapy evaluations, minutes, or services offered, and the Director of Rehab reported there was no speech therapy in place, only a recently hired PRN speech therapist, and that there had been no restorative program since their start at the facility. The DON acknowledged awareness of the lack of therapy and the absence of a restorative therapy program.

Interviews with nursing staff and administration revealed systemic staffing and orientation problems. One LPN, initially an agency nurse who became a direct hire, stated being a brand-new nurse who received no orientation and was unaware of how poor staffing levels were. Another LPN reported it was their first day in the building, had never worked there as agency staff, and was working solo since early morning without training, relying on resident charts and other LPNs for questions. A third LPN described ongoing short staffing since new management took over, with only one night nurse until very recently, heavy reliance on agency staff, and critical care needs on the units such as IV medications and wound vacs. This LPN also reported that the admissions nurse did not help on the floor when short-staffed, the wound nurse had quit, the DON was working the floor extensively, and staff turnover was high. The Administrator confirmed frequent leadership changes, heavy use of agency staff, issues with RN coverage, and that regulatory duties were not handed off between administrators, while stating that agency staffing was used to meet minimum staffing requirements and that the DON was working on a system to ensure continuity of care amid frequent staff turnover.