Failure to Provide Needed Dental Care Resulting in Pain and Severe Weight Loss
Summary
The facility failed to provide or obtain necessary dental care for a resident over a nine-month period, despite clear evidence of multiple broken teeth requiring extraction. The resident, who had Huntington's Disease and a cognitive communication deficit, was not on hospice or an end-stage diagnosis. Initial assessments documented obvious cavities and broken teeth, and the care plan identified poor dental status as a contributing factor to altered nutrition and hydration. Despite this, the resident did not receive timely dental interventions, and referrals to both external and in-house dental providers were either not completed or not followed up effectively. The facility's own dental provider visited multiple times, but the resident was not seen during these visits. During this period, the resident experienced ongoing dental pain, as confirmed by direct interviews and observations, and suffered severe, unplanned weight loss exceeding 20% over six months and 24% over nine months. Staff interviews revealed that oral pain was observed during care, but documentation of pain and physician notification was lacking. The resident's pain and difficulty eating were corroborated by both the resident and staff, yet there was no evidence of consistent or effective follow-up to address these issues. The care plan called for therapy evaluations as indicated, but a speech therapy assessment was not ordered until after surveyor intervention. Attempts to arrange for dental extractions through an oral surgeon were documented in a separate notebook rather than the medical record, and most attempts consisted of leaving messages without successful contact for months. Additional efforts to find alternative providers were limited and ceased after initial refusals. The facility's leadership acknowledged that the resident should have been included in the routine dental program and that documentation and follow-up were insufficient. The resident's physician was not notified of the dental pain, and there was no evidence of pain management or timely dental intervention documented in the medical record.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with stroke, chronic pain, trigeminal neuralgia, and bruxism had multiple dental orders for eval and treatment by the facility dentist, including for teeth grinding, but had not been seen by a dentist since admission. The resident reported no dental visit, and the MDS/scheduler confirmed the resident had not been seen despite the facility having dental services available.
Failure to obtain routine dental services for a resident with ill-fitting dentures and an edentulous mouth. Oral screenings repeatedly identified the need for a dental consult, but no documented dental visit was found since admission. The DON stated the resident had not been enrolled in the outside dental program and that this was an oversight.
Failure to follow up on recommended dental services for a resident with impaired cognition and assistance needs for oral hygiene. Dental notes documented heavy tartar and recommendations for cleaning, scaling, root planing, and x-rays, while the resident reported something stuck in his teeth and staff were told about the concern. SSD stated the family agreed to pay out-of-pocket for cleaning, the resident had no dental insurance, and the SSD did not follow up on the dental service; QA stated the resident was at risk for pain and reduced food intake leading to weight loss.
Failure to Follow Dental Recommendations and Support Denture Use: The facility did not ensure two residents received needed dental follow-up and denture support. One cognitively intact resident had documented ill-fitting dentures, but the care plan lacked specific denture interventions, no follow-up was documented, and staff were not assisting with denture placement despite the resident wanting to wear them. Another resident had loose upper and lower dentures, dental screenings called for denture adhesive, but the EMR, care plan, and room lacked evidence that the adhesive was provided, and staff confirmed the recommendation was not reflected in the resident’s care.
Failure to provide timely dental services for a resident with DM2, a below-the-knee amputation, and HTN. The cognitively intact resident requested dental hygiene and evaluation of a broken tooth causing discomfort, but the request was not followed up. The DON said dental visits occurred periodically and referrals were made for concerns, while the SSD confirmed the resident had been in the facility for two months without a baseline dental exam and that a prior dental visit did not include the resident due to insurance coverage issues.
Failure to provide routine dental care and obtain needed dental clearances delayed treatment for two residents. One resident with encephalopathy had no documented routine dental evals and, after reporting a broken partial bridge and sharp pain, no dental appt or treatment was arranged by survey exit. Another resident with dementia and severe cognitive impairment had a broken molar with infection; although the dentist prescribed antibiotics and the physician clearance was completed, the record did not show the required consent forms were completed so the recommended extraction could proceed.
Failure to Provide Ordered Dental Evaluation
Penalty
Summary
The facility failed to provide treatment to maintain dental health for Resident #1. The resident was admitted with diagnoses including stroke with left hemiparesis, status post craniotomy with swelling around the right ear, chronic pain, migraines, insomnia, trigeminal neuralgia, and bruxism, and was dependent on nursing staff for several aspects of care. The resident’s June 2026 physician orders included multiple dental orders directing that the resident be evaluated and treated by the facility dentist as needed, by facility dentist services, and specifically for bruxism. During the complaint investigation, Resident #1 stated that they had not been seen by a dentist since admission and reported a history of grinding teeth. The facility Director of Medical Records and Scheduler stated that the facility has dental services that come to the facility to consult with residents and confirmed that Resident #1 had not been seen by a dentist. The deficiency was identified from review of the complaint, clinical record, and interviews with the resident and staff.
Failure to Obtain Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for a resident who reported that dentures were not fitting well and who had no teeth in the mouth on observation. During the resident interview, the resident stated a desire to see a dentist because of the denture issue. The record showed oral screenings completed on four separate occasions, and each screening identified the resident as edentulous with a dental consult needed. Despite those repeated findings, there was no documented evidence that a dental consult was obtained at any time since the resident’s admission in April 2025. In interview, the DON stated that the facility’s outside dental company was supposed to provide annual assessments and that the resident’s chart contained no documentation of a completed dental visit. The DON later clarified that the facility offered one dentist visit and two dental hygienist visits per year through an outside company, but this resident had not been enrolled in the dental program and was described as having been overlooked.
Failure to Follow Up on Recommended Dental Services
Penalty
Summary
The facility failed to follow up on necessary dental services for one resident who was admitted with cardiomegaly, enthesopathy, HTN, and CHF. The resident’s MDS dated 4/8/2026 indicated moderately impaired cognitive skills and a need for supervision or touching assistance with oral hygiene. Social Services documentation dated 5/15/2026 stated the dentist recommended teeth cleaning and the family agreed to pay $200 out-of-pocket for the cleaning. A dental progress note dated 5/29/2026 documented a recommendation for full mouth x-rays when eligible, and a dental care note dated 6/23/2026 documented heavy tartar with recommendations for scaling, root planing, and x-rays; the resident had no dental insurance coverage and was self-paying. During a concurrent observation and interview on 6/24/2026, the resident stated there was something stuck in his teeth that he could not get out, and his mouth was observed to have crowded and overlapping teeth. The resident stated he had told staff about his concern regarding his teeth. During interview and record review on 6/25/2026, the SSD stated the family had agreed to cover the out-of-pocket cost for dental cleaning, the resident had no dental insurance, and the facility covered dental expenses if a resident needed dental services, but she did not follow up on the resident’s dental service. The SSD stated it was her responsibility to take care of residents’ dental needs. QA stated that if the resident’s dental needs and dentist recommendations were not followed up on, the resident was at risk for pain and his food intake would be negatively affected leading to weight loss.
Failure to Follow Dental Recommendations and Support Denture Use
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for two residents with documented oral health needs. One resident was cognitively intact and required partial to moderate assistance with most ADLs. That resident had a dental note documenting that dentures did not fit properly and needed adjustment, and a later MDS oral/dental assessment again noted the dentures did not fit correctly and recommended evaluation for adjustment. The care plan addressed oral/dental health and mouth care, but it did not include specific interventions for denture use, management, or follow-up, and the EMR did not show dental follow-up after the December 2025 assessment. During observation, the resident was seen without dentures and stated the dentures frequently fell out, did not fit right, and staff had stopped helping with denture use, so the resident no longer wore them consistently. The resident also stated a desire to continue using the dentures and reported gum tenderness. Staff interviews confirmed oral care was provided, but staff were not assisting with denture placement or use and were unaware of current denture use. The HUC stated dental scheduling was variable and was not aware of when the resident last received follow-up for the dentures, and the RN and LPN also confirmed there was no current documentation or follow-up addressing the denture issue. A second resident had intact cognition, no behavior issues, and diagnoses including diabetes, heart disease, kidney disease, and partial amputation of the left foot. The resident’s EMR, including the care plan, physician orders, and progress notes, did not identify denture adhesive even though dental screening assessments stated to provide denture adhesive and noted the resident was concerned the dentures were loose. During observation and interview, the resident stated the upper and lower dentures did not fit properly, that the facility had said it would address the bottom dentures weeks earlier, and that the lower dentures fit so poorly the resident worried about losing them. No denture adhesive was present in the room or bathroom, and staff interviews confirmed the adhesive was not in the room and was not reflected in the care plan. The DON stated the facility did not have a reliable process to ensure dental recommendations were consistently followed, documented, and incorporated into the care plan.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide routine and emergency dental services for one resident who had been admitted with diagnoses including type 2 diabetes, a right below-the-knee amputation, and hypertension. The resident’s MDS dated 4/15/2026 showed a BIMS score of 13, indicating the resident was cognitively intact, and the resident required assistance with ADLs and mobility. The care plan identified the resident as at risk for cardiovascular symptoms or complications. During an interview on 6/10/2026, the resident stated a desire to see the dentist, have dental hygiene performed, and have a broken tooth evaluated, and reported discomfort from the broken tooth. The resident said the request had been told to a staff member but no follow-up occurred. The DON stated dental services came to the facility every three to six months and that referrals were submitted for residents with concerns. The SSD stated the dental provider visited one to two times per month, that newly admitted residents should receive a baseline dental exam, and that the resident had been in the facility for two months without being seen by dental. The SSD also stated dental was on-site on 4/29/2026 but did not see the resident because of insurance coverage issues, and no follow-up occurred regarding which residents were seen. The facility policy stated emergency and routine dental services would be provided according to assessment and plan of care, and social services was to facilitate dental appointments.
Failure to Provide Timely Dental Services and Required Clearances
Penalty
Summary
The facility failed to provide routine dental services and failed to obtain required dental clearances needed to facilitate recommended dental treatment for two residents. The facility policy stated it would assist residents in obtaining routine and 24-hour emergency dental care. For one resident admitted with encephalopathy, the clinical record showed no evidence of dental consultations or evaluations for routine dental services from admission through survey. When the resident reported feeling something sharp in the left lower jaw and believed a partial bridge was broken, the facility notified contracted dental services, learned the contracted provider did not accept the resident’s insurance, and then contacted the responsible party for the community dentist information, but no dental appointment or treatment had been arranged by survey exit. For another resident admitted with dementia, agitation, dysphagia, and a history of protein calorie malnutrition, the record showed severe cognitive impairment on MDS assessment and a nursing note documenting a broken molar causing oral pain. Contracted dental services evaluated the resident and identified an infection in tooth number two, prescribing Clindamycin and recommending saltwater rinses while awaiting physician and responsible party clearance for extraction. The physician clearance form was completed, and the resident received all prescribed antibiotic doses, but the record did not show that the responsible party completed the consent forms needed for the dentist to proceed. The DON stated the resident’s family lived out of the country and the responsible party was difficult to contact and struggled with medical decisions, and the record did not demonstrate timely and necessary actions to obtain the required consent and clearances for the recommended tooth extraction.
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