F0677

E

Failure to Provide and Document Oral Care, Toileting, and Repositioning for Dependent Residents

Council Bluffs, Iowa Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document required assistance with oral care, toileting, and repositioning for multiple dependent residents. For Resident #22, the Quarterly MDS dated 10/31/2025 showed a BIMS score of 4, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with oral hygiene. Her care plan, revised 11/18/2020, identified an ADL self-care performance deficit related to multiple sclerosis and required one staff to assist with daily grooming, including personal hygiene and oral care. A handwritten sign in her room requested that staff brush her teeth every day, and her emergency contact reported that her teeth were sometimes not brushed much when she visited, stating the resident would allow staff to complete oral care. On interview, the resident stated staff had not brushed her teeth that morning. The DON later stated she was unaware of the sign and that oral care should be completed at least twice a day, ideally by CNAs but also by nurses or other clinical staff, and possibly during OT.

Resident #2’s MDS documented a BIMS of 15, indicating no cognitive impairment, and a need for supervision or touching assistance for oral hygiene. Her care plan, initiated 12/5/2025, documented that she required assistance of one staff for oral care. Review of her EHR showed no documentation of oral care provided. In interview, she stated she had a toothbrush in her bathroom and that whether oral care was provided depended on the staff. She reported that her husband helped her brush her teeth in the evenings, OT used to help her when she was going to therapy, and that occasionally a CNA would assist her with oral care. Resident #3’s MDS showed a BIMS of 11, indicating moderate cognitive impairment, and a need for partial/moderate assistance with oral hygiene. Her care plan, initiated 4/12/2025, documented that she required assistance of one staff for oral care, yet her EHR contained no documentation of oral care. Observation revealed no toothbrush in her room, and the ADON confirmed there was no equipment available to provide oral care. A CNA stated she had completed oral care that morning, claimed she obtained a new toothbrush for the resident every day, and said the resident only required set-up according to the care plan, which conflicted with the documented need for assistance.

Resident #29’s MDS documented a BIMS of 15 and a need for supervision or touching assistance for oral hygiene, and her care plan dated 11/19/2025 indicated she required assistance of one for oral care. Her EHR contained no documentation of oral care. She reported that she had to set an alarm on her phone to ensure staff came to reposition her every two hours as ordered by her doctor, and that prior to a hospital stay staff were not repositioning her every two hours, with some overnight shifts only repositioning her at 3:00 or 4:00 AM. She stated she had multiple sclerosis, could not reposition herself in bed, and required staff assistance. She also reported that staff rarely provided oral care, that she could not sit up in bed on her own, and that she would appreciate staff assistance with oral care. She further stated that on one night a CNA refused to change her brief, that she was out of briefs and remained incontinent of urine without being changed all night, and that this CNA only repositioned her but did not change her. She reported prior concerns about this CNA’s care and described feeling treated without appropriate dignity or respect when requesting to be cleaned and changed.

Resident #30’s MDS documented a BIMS of 13, indicating no cognitive impairment, and a need for substantial/maximal assistance with oral hygiene. Her care plan, initiated 12/3/2025, documented that she required assistance of one for oral care, yet her EHR contained no documentation of oral care. Her daughter reported that when she visited at random times, she frequently found food on the resident’s face and mouth and that it appeared her mother’s teeth had not been brushed. Staff interviews confirmed expectations and practices related to oral care: the ADON stated it was an expectation that all residents receive oral care even if they do not have teeth, and that dentures should be cleaned or soaked overnight. The DON stated oral care should be completed or offered and documented if refused, and that the required assistance should be reflected on the care plan. A CNA described asking cognitively intact residents when they wanted their teeth brushed and providing oral care before breakfast for residents who were not cognitively aware, and reported frequently finding residents with food on their faces and hands not cleaned from dinner, which she had brought to management’s attention.

Review of the facility’s undated oral care policy showed that the purpose of the procedure was to keep lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection. The policy required review of the care plan for special needs, assembly of needed equipment and supplies, and documentation in the medical record of the date and time mouth care was provided, the name and title of the person providing care, assessment data about the mouth, complaints of pain or discomfort, refusals with reasons and interventions, and the signature and title of the person recording the data. The policy also required CNAs to report to the licensed nurse for documentation. Despite these policy requirements and the care plan directives, surveyors found no documentation of oral care for multiple residents who required assistance, observed lack of oral care supplies in at least one resident’s room, and obtained resident and family reports that oral care, toileting, and repositioning were not consistently provided as needed.