Failure to Track and Replace Lost Dentures for Two Residents
Summary
The facility failed to track, locate, replace, and follow up on lost dentures for two residents, resulting in both individuals being without their dentures for an extended period. One resident, admitted for heart failure and with intact cognition, required assistance with oral hygiene and had upper dentures on admission. Her dentures were lost approximately two months prior to the survey, and despite repeated inquiries, the facility did not provide updates or facilitate replacement, leaving her to eat only soft foods and feel blamed for the loss. The resident reported emotional distress due to the situation, and staff confirmed awareness of the missing dentures but had not resolved the issue. Another resident, admitted with cerebral infarction and end-stage renal disease on hemodialysis, also required assistance with oral hygiene and had both upper and lower dentures on admission. His dentures were lost, and although a dental appointment was scheduled, neither he nor his family received follow-up communication from the facility. The resident was forced to use ill-fitting temporary partials, which impaired his ability to eat and speak, and negatively affected his social interactions and self-esteem. Staff interviews revealed a lack of a tracking log for lost dentures and uncertainty about whether the issue was discussed in interdisciplinary meetings. The facility's policy required investigation and documentation of lost property, but this process was not followed for these cases.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with no upper teeth and multiple missing lower teeth did not have the Social Services Initial Psychosocial Assessment completed, leaving the dental ancillary services section blank. Staff stated there was no dental mobile consult pending, and the DSS, DON, and an LVN acknowledged the resident's dental needs were not identified or followed up through the admission assessment process.
A resident with stroke-related diagnoses and intact decision-making capacity lost his upper dentures in the facility and was charged $800 for replacement. The resident said he filed a grievance after being told to pay for the dentures, while SS confirmed the dentures were listed in his inventory and the facility could not locate them. The DON stated the resident should not have been required to cover the cost because the dentures were misplaced in the facility.
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 Assess and Follow Up on Dental Needs
Penalty
Summary
The facility failed to assess and follow up with necessary dental services for one resident who had no upper teeth and multiple missing lower teeth with no partial dentures. The resident was admitted with diagnoses including COPD, osteoarthritis, hypertension, and CHF, and the MDS dated 4/14/2026 indicated intact cognition and substantial to maximal assistance needed with toileting hygiene, bathing, and upper body dressing. The care plan noted the resident had no teeth in the upper jaw and multiple missing teeth in the lower jaw and included interventions to coordinate dental care and refer the resident to a dentist for evaluation. The Social Services Initial Psychosocial Assessment dated 5/8/2026 was not completed, and the ancillary services section for vision, dental, hearing, and podiatry was left blank. During observation on 7/7/2026, the resident was seen with missing upper and lower teeth. SSA 1 stated there was no dental mobile consult done or pending. The DSS stated he was responsible for the admission assessment and that the psychosocial assessment should have been completed to capture necessary ancillary services, and that without it the resident's dental needs would not be met or identified. The DON and LVN 5 also stated the resident's missing teeth could affect chewing and care, and the Social Services Specialist job description stated the role included ensuring residents receive necessary evaluation for dental needs and follow up as required.
Resident Charged for Lost Dentures
Penalty
Summary
The facility failed to ensure that one resident was not charged for the loss of dentures when the resident paid $800 for replacement of lost upper dentures. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and the H&P indicated the resident had capacity to understand and make medical decisions. The MDS indicated the resident could make self-understood and understand others, but needed assistance with oral and personal hygiene, toileting, bathing, and transfers. The resident’s concern record showed the full upper dentures were lost and the resident could not recall where they were left. The resident stated he filed a grievance after losing the upper denture and was frustrated that he had to pay $800 for replacement when it was not his fault. Social services confirmed the dentures were listed in the resident’s inventory and that the facility investigated the loss but could not locate them. Social services also stated the resident was told he had to pay $800 for timely availability of the denture and that the family was willing to cover the cost. The DON stated that because the denture was misplaced in the facility, the resident was not required to pay for it and reimbursement should have been facilitated, while the facility policy stated lost or damaged dentures would be replaced at the resident’s expense unless facility staff were responsible for the damage.
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.
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