Inspection·June 28, 2023

F 0791 regarding resident's missing dentures. Level of Harm - Minimal harm or potential for actual harm Review of social service progress note dated 06/01/23 per Social Service Designee (SSD) #172 revealed she and the Administrator spoke to Resident #51's guardian about his dentures. Resident got lower dentures in 2022 and insurance would only cover dentures every 10 years. Guardian was made aware of this. SSD #172 contacted the dentist, and the dentist would reach out to the guardian as well on how to go about replacing resident's dentures. Residents Affected - Few Review of the dental prior authorization for Resident #51 dated 06/16/23 revealed there would be no charge to replace resident's upper denture. Replacement of the lower denture would cost $1200. Interview on 06/28/23 at 12:21 P.M. with the Administrator confirmed she started working with the facility at the end of March 2023 and that sometime near the end of May 2023 Resident #51's guardian told her the resident's dentures were missing. Administrator confirmed SSD #172 told her the dentures got lost when resident went out to a doctor appointment with the guardian. Administrator confirmed in June 2023 the facility got a quote from the dentist on the cost of replacing the dentures. Administrator confirmed the lower dentures cost $1200 and Medicaid would not cover this. Administrator confirmed it was her understanding that the resident/guardian were responsible for paying for the dentures because they got lost when resident was out of the facility with the guardian. Observation on 06/28/23 at 12:52 P.M. of Resident #51 revealed he was edentulous and had no dentures in his mouth or in his room. Interview with Resident #51 at the same time confirmed his dentures got lost a few months ago and he did not remember where or how they got lost. Resident #51 confirmed he was embarrassed by not having teeth and he was upset that the facility had not helped him replace his dentures. Interview on 06/28/23 at 2:41 P.M. with the Director of Nursing (DON) and SSD #172 confirmed Resident #51 was admitted to the facility in 2020 and had upper and lower dentures. SSD #172 confirmed Resident #51 went to a neurology appointment with the guardian on 02/06/23 and when he returned, he had no dentures in his mouth. DON confirmed the facility called the doctor's office, and they did not have Resident #51's dentures. SSD #172 confirmed the facility called the guardian and she did not know what happened with the dentures. The guardian said she had not transported him back to the facility but did not provide information regarding who transported the resident back to the facility. DON confirmed the guardian was upset about the resident's dentures at the care conference on 04/18/23, but it was the guardian's responsibility to replace the dentures since the resident lost them when he was out of the facility. Interview on 06/28/23 at 4:15 P.M. with the Administrator and the DON confirmed Resident #51's payor source was Medicaid and he was admitted with upper and lower dentures. Resident #51's dentures were noted to be missing on 02/06/23 after resident returned from a doctor appointment. The referral to the dentist was dated 06/16/23. The resident's record had no documentation regarding the reason for the delay in referral to the dentist nor the potential effect on the resident of having his teeth missing for several months. The facility had no documentation of investigation regarding how and when the dentures got lost. Review of the undated facility policy titled Denture Loss or Damage revealed dignity and self-esteem may be compromised when the resident does not have their dentures. Speech or communication may also be compromised. For these reasons and more it is imperative that missing dentures be replaced in a timely manner. Dentures that are reported broken or lost shall be replaced with the assistance of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility staff. A referral will be made within three days of the missing or broken dentures reported. Social Service will place a referral for a dental consult within three days. If a referral does not occur within three days, the facility must provide documentation that the resident was assessed for the ability to eat and drink adequately while waiting for dental services and the reason for the delay. An investigation will be performed to determine if loss or damage of the denture was the result of facility neglect or mishandling. The facility will replace broken or lost dentures at the cost to the facility if the investigation reveals that the facility was negligent and/or irresponsible with handling and that the resident had that denture on admission. This deficiency represents non-compliance investigated under Complaint Number OH00143672. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 If continuation sheet Page 3 of 3