F0585

D

Failure to Investigate and Resolve Grievance Regarding Resident’s Missing Teeth

Ottawa, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to honor a resident’s right to voice grievances and have them promptly investigated and resolved when the resident’s daughter reported concerns about the resident’s missing natural teeth. The daughter stated that about a month prior she had raised concerns to staff, including the Administrator and DON, about how the resident lost at least one tooth and questioned whether it had come off in the resident’s mouth and what caused it to fall out. As of the survey date, she reported that no one at the facility had provided her with an explanation of what happened. A CNA reported that a couple of weeks earlier she observed the resident, who has dementia and is nonverbal, tapping her mouth and appearing to have lost a tooth, and that she reported this to a nurse who said the resident would be referred to a dentist.

Progress notes dated 1/27/26 documented an oral visual check with no pain, discomfort, redness, or swelling of the gums, and noted one right lateral tooth missing, with the daughter aware. The DON stated that an email was sent to the daughter on 1/27/26 indicating the facility was looking into how the tooth became missing, and that on 1/30/26 the daughter reported additional missing teeth based on the resident’s profile picture, for a total of two missing teeth. As of the survey date, the DON acknowledged there had been no update to the daughter because no one knew what had happened to the missing tooth, and the resident had not been referred to a dentist. Review of the facility’s grievance log showed that the daughter’s concerns about the missing tooth were not entered, and both the Administrator and DON confirmed the concern should have been logged with a resolution, contrary to the facility’s grievance policy requiring investigation and communication of findings within specified time frames.