Failure to Care Plan and Implement Oral and Denture Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and update a comprehensive, person-centered care plan addressing a resident’s oral care and denture needs. The resident, an adult male admitted with COVID-19, acute kidney failure, low back pain, hypertension, Barrett’s esophagus, and dysphagia, had a BIMS score of 14 indicating intact cognition and required setup assistance with eating and partial to moderate assistance with oral hygiene. The admission MDS documented that the resident had loss of liquids/solids from the mouth while eating or drinking and retained food in the mouth after meals, and he was on a mechanically altered diet. Despite these identified needs, the care plan dated 12/20/2025 only addressed an ADL self-care performance deficit and risk of unmet needs in general, with interventions such as therapy to screen, evaluate, and treat as needed, but did not include specific interventions for oral care or denture care. Interviews and observations further demonstrated that the resident’s oral and denture needs were not incorporated into the care planning process or communicated in a consistent, written manner. A hospital RN reported that the resident was admitted to the hospital without dentures in place, with impacted food in the gum line and a large glob of pink denture adhesive lodged in the back of his throat that required suctioning, and expressed concern about lack of oral care at the facility. The resident’s family member stated the resident previously wore dentures all the time but had difficulty with them after weight loss, was having problems eating, and that staff were supposed to assist with feeding and mouth cleaning. The speech therapist confirmed the resident had dentures that were poorly fitting and that he was on a puree diet, keeping food at the front of his mouth due to decreased tongue strength. A CNA stated he did not recall whether the resident had dentures or teeth and that there was no written place to see if a resident required oral or denture care, relying instead on verbal report. An LVN and the DON both acknowledged that oral and denture care should have been included in the care plan and that nurse managers were responsible for ensuring the care plan accurately reflected such needs, which would then be assigned to CNAs via the task system. The facility’s written policy required comprehensive care plans with measurable objectives and timeframes to meet identified needs, including services to attain or maintain the resident’s highest practicable well-being, but this was not implemented for the resident’s oral and denture care needs.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.