F0725

E

Insufficient Nursing Staff Leading to Missed Baths and Delayed Call Light Response

Odessa, Missouri Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly related to timely response to call lights and provision of scheduled baths/showers. The facility’s own Sufficient Staff Policy requires adequate numbers of licensed nurses and CNAs on a 24-hour basis, consideration of census and acuity, and ensuring staff have the competencies to carry out resident care plans. Resident council minutes over three consecutive months documented repeated resident reports that there were not enough workers, call lights were not answered promptly, beds were not being made, linens were not being changed without reminders, and residents were not receiving two showers per week as expected.

One cognitively intact resident required substantial/maximal assistance with bathing and dressing and reported that staff were slow to answer call lights at all times of day and that only one bath per week was being provided instead of the two baths ordered. Another resident with moderate cognitive impairment, who required substantial/maximal assistance with bathing and supervision or touching assistance for dressing, similarly reported that night shift staff were slow to answer call lights and that only one weekly bath was being received instead of the expected two. The DON confirmed that these residents should have received two baths/showers per week and that call lights were to be answered within 10 minutes, but the residents’ statements and council minutes showed these expectations were not being met.

Multiple staff interviews further demonstrated that staffing levels and assignments were insufficient to consistently complete required care. The designated bath aide reported being the only person assigned to baths/showers, with responsibility for about 20 showers per day for a 60-resident census, and stated that residents sometimes did not receive baths if the aide was pulled to help with feeding, transfers, or if residents had appointments. CNAs and a CMT reported that the facility was short staffed on all shifts, that they were unable to complete all assigned work without coming in early or staying late, and that when the bath aide was absent, floor CNAs were expected to cover baths in addition to regular duties. Staff also described delays in obtaining assistance for mechanical lift transfers and the Activity Director reported being pulled from scheduled activities to assist with direct care tasks, resulting in missed activities. These observations and interviews collectively show that the facility did not maintain sufficient nursing staff to ensure residents consistently received timely call light response and two baths per week as care-planned.