Inspection Reports for
Odessa Health Care Center
609 GOLF ST, ODESSA, MO, 64076-1462
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
56 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Date: Jun 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate assistance with activities of daily living (ADL), insufficient staffing, lack of registered nurse coverage, and issues with food temperature and quality at Odessa Health Care Center.
Complaint Details
The investigation was complaint-driven with complaint numbers MO00255324, MO00255403, MO00255632, and MO00255047. Complaints included inadequate bathing and hygiene care, insufficient staffing including lack of RN and DON coverage, cold and unappetizing food, and unlicensed staff performing resident care.
Findings
The facility failed to provide adequate ADL care including bathing and grooming for sampled residents, had insufficient nursing and certified staff coverage including lack of RN and DON presence, and served food that was often cold and unappetizing. Non-certified staff were performing resident care without proper training or certification, and administrative oversight was lacking.
Deficiencies (6)
Failure to carry out activities of daily living (ADL) to maintain grooming and personal hygiene for sampled residents.
Failure to provide sufficient nursing staff 24/7 to meet resident needs and ensure safety.
Failure to have a registered nurse on duty at least 8 consecutive hours per day and designate a full-time Director of Nursing.
Failure to ensure food was served at a safe and appetizing temperature; residents frequently received cold food.
Failure to administer the facility in a manner that enables effective and efficient use of resources, including lack of full-time administrative and nursing oversight.
Failure to employ staff that are licensed, certified, or registered in accordance with state laws; non-certified staff performed resident care without training or certification.
Report Facts
Residents affected: 3
Facility census: 56
Missed showers: 6
Missed showers: 3
Staffing counts: 2
Room trays served: 20
Food temperatures: 102.8
Food temperatures: 99.8
Food temperatures: 99.1
Food temperatures: 101.7
Food temperatures: 67.3
Residents requiring ADL assistance: 45
Residents requiring feeding assistance: 5
Residents requiring toileting assistance: 40
Residents requiring total dependent care: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practice Nurse | Reported facility short staffing, lack of RN coverage, and Administrator covering charge nurse duties. |
| CNA A | Certified Nurse Assistant | Reported residents not getting bathed, long call light wait times, and Administrator working as charge nurse. |
| CNA C | Certified Nurse Assistant | Reported residents going weeks without bathing, short staffing, and unsafe transfer practices. |
| CNA D | Certified Nurse Assistant | Observed residents soiled due to inadequate care and short staffing. |
| CNA E | Certified Nurse Assistant | Reported residents not getting showers due to staffing shortages and informed Administrator. |
| Administrator | Facility Administrator | Frequently covered charge nurse duties, mandated non-certified staff to work floor, acknowledged staffing and RN coverage issues. |
| Dietary Staff A | Dietary Staff | Reported short staffing in dietary, delayed meal delivery, lack of heated tray covers, and cold food complaints. |
| Dietary Staff B | Dietary Staff | Reported staff disciplinary actions and food being prepared hours in advance leading to cold meals. |
| Dietary Staff C | Dietary Staff | Under 18, worked overnight shift, answered call lights, and was mandated to work to meet fire code. |
| Environmental Services Staff A | Environmental Services Staff | Assisted with resident cares without certification or training, felt uncomfortable performing duties. |
| Activities Director | Activities Director | Reported Administrator spent most time in office and facility lacked nursing supervision most days. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Date: Apr 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding insufficient nursing staff coverage, lack of RN and Director of Nursing (DON) presence, and failure to post nurse staffing information as required.
Complaint Details
Complaint # MO 00251633 regarding inadequate staffing, lack of RN and DON coverage, and failure to post staffing information.
Findings
The facility failed to maintain adequate nursing staff on night shifts, did not have RN coverage for eight hours per day, seven days a week, lacked a full-time DON onsite, and failed to post daily nurse staffing information accessible to residents and visitors. Staffing shortages were observed and confirmed through interviews and record reviews.
Deficiencies (3)
Failed to provide enough nursing staff every day to meet resident needs and have a licensed nurse in charge on each shift, including inadequate night shift staffing.
Failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week, and failed to ensure a Director of Nursing (DON) was onsite full-time.
Failed to post nurse staffing information daily in a location easily accessible to residents and visitors, including facility name, daily census, and actual hours worked per shift for nursing staff categories.
Report Facts
Census: 54
Staffing hours: 6.03
Staffing requirement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in staffing deficiency and interview regarding night shift coverage |
| CNA A | Certified Nurse Aide | Named in staffing deficiency and interview regarding night shift coverage |
| Regional Chief Nursing Officer | Regional CNO | Interviewed regarding staffing and RN coverage |
| Interim DON | Director of Nursing | Newly arrived interim DON interviewed about staffing and coverage |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding staffing scheduling and DON resignation |
| Social Services Designee | Social Services Designee | Interviewed about staffing schedule and assistance with resident care |
| Regional CEO | Regional CEO | Interviewed about DON resignation and staffing arrangements |
| Interim OPS Manager | Interim Operations Manager | Interviewed about absence of DON and RN coverage |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of resident property when a Certified Nursing Assistant (CNA) borrowed $150 from a resident to pay court costs.
Complaint Details
The complaint was substantiated as the CNA borrowed $150 from Resident #3 without proper consent. The resident was refunded the money and the CNA was terminated. Police were contacted but could not take action as the money was considered a loan.
Findings
The facility failed to prevent misappropriation of resident property by a CNA who borrowed $150 from a resident. The CNA was terminated, the resident was refunded the money, and the facility took corrective actions including staff reeducation and investigation.
Deficiencies (1)
Failed to protect resident from wrongful use of belongings when CNA borrowed $150 from resident.
Report Facts
Residents present: 53
Amount misappropriated: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in misappropriation finding; terminated for no call no show and involved in borrowing money from resident |
| Administrator A | Administrator | Notified of incident and investigation lead |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Notified of past non-compliance and involved in investigation |
| Director of Nursing | Director of Nursing (DON) | Started investigation immediately upon notification |
| Activities Director | Activities Director | Notified Administrator of resident's concern and provided written statement |
| Social Service Director | Social Service Director | Provided written statement regarding resident interview |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's responsible party after a choking incident and subsequent medical changes for Resident #3.
Complaint Details
The complaint investigation found that the resident's representative was not notified of the choking incident, x-ray results, or new medications ordered. The resident's representative learned of the incident from the resident's spouse. Staff interviews confirmed responsibility for notification but failure to notify occurred.
Findings
The facility failed to notify the resident's responsible party after staff performed the Heimlich Maneuver on Resident #3 who choked on food, and did not relay physician-ordered medication changes and tests to the responsible party. Staff were educated on notification policies and the deficiency was corrected.
Deficiencies (1)
Failure to notify the resident's responsible party after a choking incident and subsequent medical changes.
Report Facts
Residents Affected: 3
Facility Census: 54
Medication dosage: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding notification responsibilities and in-service training |
| Director of Nursing | Director of Nursing (DON) | Interviewed about notification responsibilities and staff in-service |
Inspection Report
Annual Inspection
Census: 49
Capacity: 60
Deficiencies: 19
Date: May 28, 2024
Visit Reason
The annual inspection was conducted to assess compliance with state and federal regulations including resident care, medication management, infection control, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to conduct proper background checks, incomplete resident assessments, inadequate care planning, medication errors, infection control lapses, staffing shortages, and financial management issues. Several residents' care plans and medication regimens were not properly managed, and infection prevention protocols were not fully implemented.
Deficiencies (19)
Failed to check the Nurses' Aide Registry for new employees prior to hire and did not complete checks for four sampled employees.
Failed to accurately complete the Minimum Data Set (MDS) for two sampled residents.
Failed to ensure completion, submission, and retention of a Level I Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (PASRR) for one resident.
Failed to provide baseline care plans to two sampled residents and/or their responsible parties within 48 hours of admission.
Failed to develop a comprehensive, person-centered care plan for one sampled resident.
Failed to hold medications according to physician's orders and failed to obtain physician's orders for colostomy care for two sampled residents.
Failed to ensure necessary information was communicated to the resident and receiving health care provider at discharge for one sampled resident.
Failed to ensure a Registered Nurse was on duty eight hours per day, seven days per week.
Failed to provide addiction recovery program or psychological services for one resident needing such services for liver transplant eligibility.
Failed to respond to pharmacist's monthly medication regimen review and failed to follow physician's order for medication management for three sampled residents.
Failed to implement gradual dose reductions and appropriate monitoring for antipsychotic and psychotropic medications for one sampled resident.
Failed to hold insulin per physician's orders for one sampled resident.
Failed to observe resident self-administering medications and failed to keep medication carts locked when not in use.
Failed to procure and maintain adequate supplies and services, including laundry chemical pumps, cleaning supplies, and laboratory services due to unpaid bills.
Failed to maintain infection prevention and control program including Legionella risk management, tuberculosis screening, hand hygiene, enhanced barrier precautions, and wound care practices.
Failed to ensure staff washed hands during medication administration and failed to follow enhanced barrier precautions during wound care and IV medication administration.
Failed to ensure wound VAC was not placed on the floor and that wound care supplies were handled with proper infection control.
Failed to ensure tuberculin skin tests (TST) were administered and read timely for residents and employees.
Failed to ensure oxygen equipment was maintained in a sanitary condition including dated tubing and humidifiers for three sampled residents.
Report Facts
Facility census: 49
Total capacity: 60
Past due invoice amount: 46480.77
Past due invoice amount: 6373.48
Medication administration errors: 1
Medication carts unlocked observations: 2
TB tests late: 8
Missing TST read dates: 5
Medication regimen review responses missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to medication administration and wound care |
| LPN A | Licensed Practical Nurse | Named in findings related to medication administration and wound care |
| Administrator | Facility Administrator | Named in interviews regarding facility operations and vendor payments |
| DON | Director of Nursing | Named in findings related to medication management, staffing, infection control |
| ADON | Assistant Director of Nursing | Named in findings related to medication management, infection control, TB screening |
| SSD | Social Service Designee | Named in findings related to PASRR screening and addiction recovery services |
| Floor Technician A | Maintenance Staff | Named in findings related to supply ordering and laundry chemical issues |
| Laundry Supervisor | Laundry Supervisor | Named in findings related to laundry chemical usage |
| Medical Director | Medical Director | Named in interview regarding lab services |
| CMT A | Certified Medication Technician | Named in findings related to medication cart security and infection control |
Inspection Report
Routine
Census: 27
Deficiencies: 21
Date: Sep 15, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, safety, infection control, and administrative procedures.
Findings
The facility was found deficient in multiple areas including failure to conduct resident council meetings, improper management of resident funds, incomplete employee background checks, untimely and incomplete Minimum Data Set (MDS) assessments, inadequate care planning, insufficient activities programming, failure to coordinate hospice care, inadequate wound care and pressure ulcer management, unsafe use of equipment, improper handling of oxygen and respiratory supplies, failure to post nurse staffing information, poor infection control practices, and lack of an effective antibiotic stewardship program.
Deficiencies (21)
Failed to ensure monthly resident council meetings were held to allow residents and families to voice concerns.
Failed to print and distribute quarterly statements for residents' personal funds managed by the facility.
Failed to complete required criminal background checks, employee disqualification listings, and nurse aide registry screenings for several employees.
Failed to complete and submit comprehensive and significant change Minimum Data Set (MDS) assessments timely for multiple residents.
Failed to ensure a baseline care plan was developed within 24 hours of admission for residents.
Failed to develop and implement comprehensive care plans reflecting residents' current conditions including hospice care.
Failed to provide an ongoing activities program that met residents' physical, mental, and psychosocial needs.
Failed to coordinate hospice care including communication, documentation of visits, and care planning.
Failed to provide timely wound care assessments, treatment orders, wound measurements, and documentation for residents with pressure sores.
Failed to lock wheels on mechanical lift and wheelchair during resident transfers.
Failed to change PICC line dressing weekly and to create a baseline care plan for PICC line management.
Failed to properly store oxygen tubing, nasal cannulas, and breathing treatment masks when not in use.
Failed to obtain physician orders, conduct safety assessments, update care plans, and monitor safety for use of bed side rails.
Failed to ensure food was palatable and to provide a mechanism for residents to voice concerns about food quality.
Failed to ensure food was prepared in a form consistent with residents' diet orders, including soft/mechanical soft diet requirements.
Failed to maintain clean food storage and preparation areas including buildup of dust, food debris, and expired food items.
Failed to keep trash containers covered in the kitchen during meal service.
Failed to implement an effective infection prevention and control program including hand hygiene, wound care infection control, infection tracking, TB screening, and blood sugar check infection control.
Failed to designate a qualified and certified Infection Preventionist to oversee the infection prevention and control program.
Failed to post nurse staffing information visibly daily for residents and visitors.
Failed to ensure a licensed pharmacist performed monthly drug regimen reviews and that recommendations were obtained and followed up.
Report Facts
Facility census: 27
Deficiency count: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in hand hygiene and infection control deficiencies during incontinence care |
| LPN A | Licensed Practical Nurse | Named in wound care and infection control deficiencies |
| LPN B | Licensed Practical Nurse | Named in wound care, PICC line dressing, and infection control deficiencies |
| CMT A | Certified Medication Technician | Named in infection control and activities program deficiencies |
| CMT B | Certified Medication Technician | Named in infection control and activities program deficiencies |
| DON | Director of Nursing | Named in multiple interviews regarding deficiencies and expectations |
| Administrator | Facility Administrator | Named in interviews regarding resident council and food palatability |
| DM | Dietary Manager | Named in food palatability and kitchen cleanliness deficiencies |
| BOM | Business Office Manager | Named in resident funds management and activities program deficiencies |
| MDS Coordinator | Minimum Data Set Coordinator | Named in MDS, care planning, infection control, and wound care deficiencies |
Inspection Report
Annual Inspection
Census: 29
Capacity: 60
Deficiencies: 4
Date: Jan 7, 2020
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal regulations regarding resident care, medication management, staffing, and food safety.
Findings
The facility was found deficient in accurately documenting significant changes in resident status on the Minimum Data Set (MDS), reconciling medications upon resident discharge, posting nurse staffing hours, and maintaining sanitary food preparation equipment and proper staff hygiene. Deficiencies were noted in care planning, medication disposition documentation, staffing information posting, and kitchen cleanliness.
Deficiencies (4)
Failure to ensure significant changes in resident status were accurately documented on the MDS for three sampled residents.
Failure to reconcile resident's medication upon discharge, including lack of documentation of quantity of pills remaining.
Failure to post hours worked by licensed and unlicensed nursing staff per shift at the nurses' station.
Failure to maintain safe, sanitary, and easily cleanable food preparation equipment and serving utensils, and failure to ensure hairnets fully covered kitchen staff hair.
Report Facts
Facility census: 29
Licensed capacity: 60
Weight decrease percentage: 14.2
Number of sampled residents with MDS deficiencies: 3
Number of sampled closed record residents with medication reconciliation deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided interviews regarding MDS documentation, medication reconciliation, and staffing postings | |
| MDS Coordinator | Provided interviews regarding MDS documentation and corrections | |
| Licensed Practical Nurse (LPN) A | Provided interview regarding medication disposition sheet completion | |
| Dietary Manager | Provided interview regarding kitchen sanitation and staff hygiene |
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