The man, who requires assistance with daily activities due to end-stage kidney disease and muscle weakness, sat in his wheelchair eating lunch when inspectors interviewed him on September 30. Staff never offered to brush his teeth in the morning, he said. When inspectors checked his cabinet drawers with his permission, they found no toothbrush, toothpaste or mouthwash.
"He does not and has never had a toothbrush, toothpaste or mouthwash for oral care since being admitted," according to the October inspection report.
A second resident told the same story. The cognitively intact man with diabetes said staff never offered him oral care in the morning, though he would like to have his teeth brushed. His cabinet drawers were also empty of any dental hygiene supplies.
"No one had given him those items since coming to the facility," inspectors wrote after interviewing him on September 30.
The residents' care plans specifically called for assistance with activities of daily living, including oral hygiene. One resident's assessment indicated he needed "setup or clean-up assistance" with oral care, meaning staff should prepare supplies and help before or after the activity.
When confronted about the missing oral care, a certified nursing assistant assigned to one of the residents said she hadn't offered it because she assumed the night shift had already provided it. She looked through the resident's cabinet drawers during the inspection and confirmed no dental supplies were present.
"The CNA said she always brushes her own teeth every morning, and oral care should be offered to the residents every day," the report stated.
Multiple staff members acknowledged the importance of daily oral hygiene during interviews with inspectors. A certified medication technician said oral care "should be part of the resident's morning routine every day." A licensed practical nurse noted she brushes her own teeth every morning "so her breath is not bad" and said oral care should be offered to residents each morning.
Another nursing assistant told inspectors that oral care should be provided to all residents daily, emphasizing that she maintains her own dental hygiene routine each morning followed by mouthwash.
The facility's Director of Nursing said during an October 2 interview that she expects staff to provide oral care to each resident every morning. Each resident should have basic dental supplies in their rooms, she told inspectors.
"Each resident should have a toothbrush, toothpaste and mouthwash in their rooms," the DON stated.
The inspection was triggered by a complaint and focused on the facility's failure to provide adequate oral hygiene care to residents who needed assistance. Federal regulations require nursing homes to help residents maintain good oral hygiene and dental care.
Poor oral care in nursing homes can lead to serious health complications beyond bad breath and tooth decay. Research links inadequate dental hygiene in elderly residents to increased risk of pneumonia, heart disease and other systemic infections. For residents with diabetes, like both men interviewed, poor oral health can worsen blood sugar control.
The facility received a citation for failing to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Inspectors classified the violation as causing minimal harm or potential for actual harm to some residents.
The two residents who spoke with inspectors had been admitted months earlier. One arrived in mid-August, the other sometime in July or August. Both men were able to communicate clearly with inspectors and understand the questions being asked.
The nursing assistant who discovered the missing supplies during the inspection acknowledged the oversight represented a failure in basic care. Despite facility policies calling for daily oral hygiene assistance, the residents had gone without this fundamental aspect of personal care for their entire stay.
The men continue to live at St Sophia Health & Rehabilitation Center on Charbonier Road, still waiting for someone to offer them a toothbrush.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Sophia Health & Rehabilitation Center from 2025-10-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for St Sophia Health & Rehabilitation Center
- Browse all MO nursing home inspections