Resident #43 arrived at the 51-bed facility on February 26 with type II diabetes and generalized anxiety. By November, federal inspectors found her sitting without any natural upper teeth.
The woman had been asking for dental care since losing the teeth. She told inspectors she wanted to see a dentist but "has not been offered assistance in obtaining a dental appointment since her admission."
Yet the facility's official assessments told a different story entirely.
Staff completed mandatory quarterly evaluations in June and September that recorded the resident as having "no oral or dental issues." The Minimum Data Set assessments are required federal forms that determine Medicare reimbursement and care planning.
When inspectors interviewed the registered nurse responsible for these assessments on November 20, she admitted uncertainty about the resident's dental condition. "She was not certain if Resident #43 had upper natural teeth," inspectors wrote.
A licensed practical nurse confirmed the obvious the next day. The resident had no upper natural teeth.
The facility's Director of Nursing acknowledged on November 25 that the resident's official assessments "did not accurately reflect the resident's oral or dental status."
The inspection followed a complaint filed with state regulators.
Federal law requires nursing homes to conduct comprehensive assessments of each resident's physical and mental condition. These evaluations must be accurate and updated quarterly to ensure proper care planning.
Dental problems pose particular risks for diabetic patients like Resident #43. Poor oral health can worsen blood sugar control and increase infection risks. Missing teeth affect nutrition and can lead to weight loss and other complications.
The resident's medical record showed she had developed polyneuropathy, nerve damage often associated with diabetes, alongside her primary diagnoses.
Inspectors classified the violation as causing "minimal harm or potential for actual harm" but noted it represented systematic assessment failures affecting the accuracy of the resident's care planning.
The case reveals how nursing homes can manipulate federal assessment data while ignoring residents' actual conditions and stated needs. Accurate MDS assessments determine not only care plans but also Medicare reimbursement rates, creating financial incentives for facilities to underreport problems.
Resident #43's situation persisted for at least five months between her June and November evaluations. During this period, she repeatedly requested dental assistance that never materialized.
The registered nurse's admission that she was uncertain about the resident's dental status suggests staff were completing federally mandated assessments without actually examining residents. The assessments require direct observation and evaluation of oral health conditions.
When inspectors observed the resident on November 19, the absence of upper teeth was immediately apparent. Yet two previous quarterly assessments had recorded no dental problems whatsoever.
The facility failed to provide basic assistance connecting the resident with dental care despite her documented requests. Nursing homes are required to help residents access necessary medical and dental services.
The Director of Nursing's final acknowledgment came only after inspectors had documented the discrepancies through observation, resident interviews, and staff questioning. The admission confirmed that official records bore no resemblance to the resident's actual condition.
Westover Retirement Community operates under complaint-based oversight, meaning inspectors typically visit only when problems are reported. This case emerged from Master Complaint Number 2673309 filed with state regulators.
The facility's assessment failures prevented proper care planning for a diabetic resident whose missing teeth could affect nutrition, medication absorption, and overall health outcomes. The woman's repeated requests for dental assistance went unheeded for months while staff documented fictional dental health status.
Federal inspectors completed their investigation on November 25, finding the facility had failed to ensure accurate resident assessments as required by law. The violation affected one of four resident assessments reviewed during the inspection.
Resident #43 remains at the facility, still seeking the dental care she requested nine months ago.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westover Retirement Community from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Westover Retirement Community
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