Failure to Provide Timely Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely oral care for a dependent resident who required assistance with activities of daily living, including oral hygiene. On 12/9/2025 at 11:05 a.m., the resident (R6) was observed in bed with a foul mouth odor. At 11:10 a.m., a CNA (V16) stated that oral care had been provided for the resident but acknowledged that the resident’s mouth had an odor. At 11:20 a.m., the DON (V2) stated that nursing assistants are expected to perform mouth care daily and as needed. Record review showed that the resident had diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left dominant side, dysphagia (oropharyngeal phase), GERD, and gastrostomy status, with an NPO diet order due to failed speech swallowing. The resident’s care plan, dated 4/17/2024, identified an ADL self-care performance deficit with impaired mobility, impaired cognition, and left-sided hemiplegia, and included an intervention for personal hygiene/oral care specifying assistance by one staff member with grooming and oral hygiene, including oral care every shift and often if needed. The facility’s ADL policy, issued 3/15/2021, requires provision of care and services for hygiene, including oral care, based on comprehensive assessment and resident needs. These observations, interviews, and record reviews demonstrate that despite the resident’s dependence and care plan requirements for oral care every shift and as needed, the facility did not ensure timely and adequate oral hygiene, as evidenced by the resident’s foul mouth odor at the time of surveyor observation.
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