HARLAN, KY - Federal inspectors discovered a resident at Harlan Health and Rehabilitation Center experienced severe dental pain for approximately one year, with the facility unable to secure proper dental care despite documentation of multiple contact attempts spanning nine months.
Resident Reports Persistent Pain
During the March 2025 inspection, federal surveyors interviewed a resident who confirmed his teeth had been causing pain "all the time" for about one year. The resident indicated the pain made eating difficult and sometimes left him hungry due to his inability to chew food properly.
When assessed by nursing staff during the inspection, the resident rated his dental pain as 10 on a 10-point scale. Physical examination revealed the resident was missing multiple teeth in both front and back areas of his mouth, with remaining teeth showing significant discoloration and some appearing partially black.
A speech-language pathologist who evaluated the resident on March 19, 2025, noted the resident's teeth were "terrible" and suggested this dental condition could explain recent weight loss. However, this speech therapy evaluation had been delayed - despite care plans from July 2023 calling for assessment "as indicated," no speech therapy order was obtained until surveyors intervened during the inspection.
Documentation and Follow-Up Gaps
Nursing staff reported being aware of the resident's dental issues. A certified nursing assistant observed the resident would "wince in pain, like someone touching a nerve" during oral care and believed this explained the resident's eating difficulties. The assistant had previously informed nursing staff about the dental pain but was told the facility was waiting for a dentist.
However, review of the resident's 2025 medical records revealed no documentation regarding dental pain or physician notification about oral health issues. Licensed practical nurse staff confirmed that protocol required notifying physicians and documenting such complaints in health status notes, yet these records contained no such entries.
The resident's physician confirmed during an interview that he had not been notified of any dental pain, though the facility had mentioned they were attempting to contact a dentist and awaiting a response.
Provider Contact Challenges
Facility administrators provided a document listing attempted contacts with an oral surgeon to whom the resident had been referred. The documentation showed 10 separate attempts between July 2024 and February 2025, with each entry noting a message was left and the facility was awaiting a callback.
The facility was able to make actual contact with the provider for the first time on March 19, 2025 - after surveyors had begun questioning the dental care delay. This contact occurred nine months after the initial referral.
Between November 11-12, 2024, the facility contacted three additional dental offices, including two general dentists and one oral surgeon. The general dentists declined because they were not oral surgeons, while the oral surgeon declined to see the resident, preferring not to treat nursing home residents or those with the resident's payment source.
No further attempts to locate alternative oral surgeons were documented after November 12, 2024, until the inspection prompted renewed efforts.
Administrative Oversight Issues
The unit manager responsible for dental referrals maintained handwritten notes in a spiral notebook at her desk rather than documenting follow-up efforts in the resident's medical record. She stated this method was "easier to work on" but acknowledged the medical record contained no information about dental care follow-up.
During interviews with facility leadership, the administrator acknowledged the resident should have been included in the facility's 360 Dental Program, calling the omission "an oversight on their part." Both the administrator and director of nursing expected dental pain to be documented in progress notes or medication administration records to ensure inclusion in 24-hour change-of-condition reports.
Additional Facility Issues
The inspection also identified problems with food service temperatures and safety protocols. Test measurements on breakfast trays over two days revealed multiple items served below recommended temperatures - sausage at 114°F and 111°F instead of the required 150°F, and eggs at 116.5°F and 111°F instead of the minimum 140°F requirement.
Multiple residents complained about cold food during a resident council meeting, with one stating food "often sat in the hallway" for up to 20 minutes before being served. Another resident reported meals were "only warm about one-half the time."
Inspectors also observed food safety violations, including kitchen staff touching food contact surfaces of plates and utensils without proper glove changes, and a dietary aide continuing food preparation after answering the telephone without washing hands or changing gloves.
Emergency Preparedness Concerns
The facility maintained 1,368 gallons of stored water for emergency use, but inspectors discovered 1,248 gallons had expired, leaving only 120 gallons of potable water available. Industry standards recommend 1.5 gallons per person per day for three days, meaning the facility needed approximately 594 gallons for its 132 residents.
Neither the maintenance director nor dietary manager was checking water expiration dates, with each assuming it was the other's responsibility.
Regulatory Standards
Federal regulations require nursing homes to ensure residents receive necessary dental care and maintain proper care coordination. Facilities must also maintain safe food temperatures and adequate emergency supplies.
The dental care delays violated standards requiring prompt attention to resident health needs and proper medical record documentation. The food temperature violations posed potential health risks through inadequate food safety protocols.
Facility Response
The facility's corporate representative acknowledged the challenges in finding dental providers willing to treat nursing home residents, particularly those with certain payment sources. However, the lack of documentation and communication gaps regarding the resident's ongoing pain raised concerns about care coordination and resident advocacy.
The inspection findings demonstrate systemic issues affecting multiple aspects of resident care, from basic medical needs to daily meal service and emergency preparedness protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harlan Health and Rehabilitation Center from 2025-03-21 including all violations, facility responses, and corrective action plans.
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