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F0557
D

Failure to Provide Dentures and Maintain Resident Dignity

Bell Gardens, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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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 ensure that a resident was provided with dentures, which impacted the resident's dignity and ability to chew food. The resident, who had a history of diabetes mellitus, epilepsy, major depressive disorder, and schizoaffective disorder, was documented as edentulous and required set-up assistance with eating and supervision for oral hygiene. Dental assessments indicated a need for full upper and lower dentures, and records showed that dentures were delivered to the facility and signed for by an unknown staff member. However, subsequent assessments and observations confirmed that the resident did not have dentures and remained edentulous. During interviews and observations, the resident expressed embarrassment about her appearance and difficulty chewing food, stating she did not know what happened to her teeth or dentures. The resident reported that staff ignored her inquiries about her missing teeth. Nursing staff, including an LVN, were unaware that the resident was eating a regular diet without dentures and acknowledged that the resident should have been on a mechanical soft diet. The Social Services Director was also unaware that the resident had received dentures and stated that staff should have notified him so the dentures could be added to the resident's inventory and replaced if lost. The facility's policies required staff to promote resident dignity, provide proper denture care, and ensure ongoing oral health assessments. Despite these policies, staff failed to ensure the resident had access to her dentures, did not communicate the loss or absence of dentures to appropriate personnel, and did not adjust the resident's diet to accommodate her edentulous status. This resulted in the resident experiencing embarrassment and difficulty eating, negatively affecting her quality of life.

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