Failure to Schedule and Follow Up on Dental Referrals
Summary
The facility failed to follow through on recommendations for outside dental consultations for two residents who required specialized dental care. One resident, with a history of multiple sclerosis, paraplegia, and cardiomegaly, was fully dependent on staff for oral hygiene and had documented dental issues including tooth decay and mobile teeth. Despite a dental provider's note indicating the need for an outside dental appointment for specific teeth, the resident was not scheduled for the recommended consultation for several months. Interviews revealed that the staff responsible for scheduling such appointments was unclear about their responsibilities and had not received adequate training on the referral process, resulting in the delay. Another resident, diagnosed with type 2 diabetes, reduced mobility, and requiring a mechanically altered diet, was identified as having significant dental issues, including cavities and broken teeth. The dental provider recommended referral to an oral surgeon for extractions prior to denture fabrication. However, the resident was not scheduled for the necessary dental extractions, and staff interviews indicated confusion and lack of clarity regarding the process for scheduling follow-up appointments. The staff member responsible for appointments had only recently taken on this role and had not been fully trained, contributing to the oversight. Facility policy required assistance with making appointments and arranging transportation for medical and professional services, including dental care. Despite this, the lack of clear procedures and staff training led to failures in ensuring timely dental services for the residents, as recommended by consulting dental providers.
Penalty
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A resident with intact cognition and multiple medical conditions reported ongoing dental pain, altered eating habits, and longstanding difficulty obtaining dental care, stating that appointments were delayed, had to be initiated by the resident, and were sometimes cancelled without explanation. Records showed a prior in-house dental visit documenting a mobile root fragment causing discomfort and the resident’s interest in extraction, but there was no evidence of follow-up, no documentation of tooth pain or dental issues in progress notes, and no Social Services documentation of offering or arranging dental services or explaining the lack of access. The SSD confirmed the absence of follow-up despite a later on-site visit by the dental provider and cited the resident’s low income and inability to cover dental liability, while the facility’s policy committed to assisting residents in obtaining routine and emergency dental care for damaged teeth and other urgent oral problems.
Nursing staff did not obtain timely dental services for a resident who was cognitively able to report symptoms and complained of toothache, burning gums, difficulty chewing, and ongoing pain, despite documented missing/broken teeth and irritated gums. An RN recorded significant oral findings and notified the physician, but the dental consult was not actually scheduled until seven days later. Key staff, including the RD and an RN caring for the resident, were unaware of the dental issues, while the DON confirmed ongoing oral discomfort managed only with pain medication. A later hospital CT showed numerous bilateral dental caries, and the consulting DDS stated he would have expected immediate notification and clearer communication from the facility when the resident first reported oral pain.
A resident with end-stage renal disease, cognitively intact and on a regular diet, had no upper teeth and reported two remaining upper back teeth that needed extraction before being fitted for a partial denture. Since admission, there was no documentation of any dental examination, and the care plan contained no dental information. The resident stated she had repeatedly asked nurses to see a dentist but was told the dentist visited while she was at dialysis. The Appointment Scheduler reported she had not been informed of these requests and confirmed, after reviewing records, that the resident had not been seen by a dentist and was not included on the list for the most recent on-site dental visit.
A resident with dementia and chronic kidney disease lost an upper denture, which staff documented and searched for but could not locate. Despite a facility policy requiring referral for lost dentures within three days and existing care plan and MD orders for dental consults as needed, a dental referral was not made for over a month, and the resident was not seen by a dentist until later for an impression for a new denture. During this delay, SLP notes documented decreased PO intake, difficulty chewing, diet downgrades to puree and then mechanical soft, and ongoing complaints about inability to chew and dislike of the softer diet. The resident was observed eating without the denture and experienced notable weight loss over this period, while the DON acknowledged an expectation for timely dental consultations for missing dentures.
A resident with hemiplegia, hemiparesis, cerebral infarction, and COPD, who was cognitively intact and on Medicaid, received a dental exam from an outside provider that resulted in a written referral for multiple tooth extractions, but there was no documentation that the extractions or any further dental services were ever completed. The contracted dental provider confirmed that the last notes were from 2024, that the resident was not enrolled in the dental program, and that no follow-up requests came from the facility or family. Facility staff, including Social Services and the DON, stated that residents should receive at least yearly dental services and that the facility was responsible for scheduling care, yet the resident had no dental services for an entire year and the facility lacked a clear dental services policy, relying instead on an undated statement that residents would be seen on an as-needed basis.
Facility staff failed to ensure two residents received required routine and follow-up dental care. One resident, observed to have few or no teeth, had no documented dental consult for over a year and had not been seen by a dentist since the prior year, despite requirements for at least annual oral assessments. Another resident with missing teeth and cavities had sporadic dental encounters, including attempted visits where the resident was unavailable or in isolation, and a recommended dental hygiene visit that was never rescheduled. A nursing note documented that a molar tooth came out while the resident was talking, and the resident was ordered to be seen by dental services, with the next documented dental visit occurring only after this event.
Failure to Provide Timely Dental Services for Resident with Documented Tooth Fragment
Penalty
Summary
Failure to ensure dental services were provided occurred when a resident with intact cognition and documented dental needs did not receive timely follow-up care. The resident, admitted with diagnoses including muscle wasting, legal blindness, and anemia, reported that obtaining dental care at the facility had always been a problem. He stated his mouth felt "weird," he had ongoing dental pain when eating, and he therefore mainly ate soft foods. He reported seeing the dentist only once and not thereafter, and described repeated issues with scheduling, including the facility attributing delays to insurance or paperwork, the resident having to initiate appointments himself, and last-minute cancellations without explanation. Despite these complaints, the resident’s MDS oral/dental section showed no responses indicating mouth or facial pain, chewing difficulty, or problems with teeth or dentures. Record review showed a dental order from an outside dental service documenting that the resident had a mobile root fragment on tooth #8 causing slight discomfort and that the resident was interested in extraction. However, there was no evidence in the progress notes of documentation of tooth pain, a broken tooth, or any follow-up dental services. Social Services notes contained no documentation of offering dental services or any rationale for the lack of access to dental care. The Social Services Director confirmed that the resident had been seen by an in-house dentist for the root fragment and expressed interest in extraction, but could not explain why no follow-up occurred and acknowledged that the resident had not been seen when the dental company was later on-site. The SSD also stated the resident’s income was very low and that he did not have enough to cover patient liability for dental services, and that attempts were being made to contact family about payment responsibility. The facility’s dental policy stated it would assist residents in obtaining routine and emergency dental care, including treatment of broken or damaged teeth or other oral problems requiring immediate attention.
Failure to Provide Timely Dental Consultation for Resident with Oral Pain
Penalty
Summary
Facility nursing staff failed to provide timely dental services after a resident reported significant oral pain. The resident, who had a history of hemiplegia following a stroke and documented missing or broken teeth, was cognitively able to report symptoms and did so, describing toothache, burning sensations in the upper and lower gums, difficulty chewing, and ongoing pain. An eInteract Change in Condition Evaluation completed by an RN on 3/9/2026 documented the resident’s report of toothache with burning gums, multiple missing and dark discolored teeth, cracked teeth, loss of lower teeth, and irritated gums. The physician was notified and a referral for a dental consultation was noted, and progress notes on 3/10/2026 indicated staff were monitoring the toothache and burning gum sensation, with gums described as slightly irritated and the resident continuing to report discomfort. Despite these findings and the facility’s Oral Healthcare & Dental Services policy stating that a consultant dentist would provide emergency dental care as needed, the actual dental consult was not scheduled until 3/16/2026, seven days after the initial complaint of oral pain. During interviews, the RD and an RN caring for the resident stated they were unaware of any issues with the resident’s teeth or chewing, and the DON confirmed the resident’s oral discomfort and that staff continued to administer pain medication. The DON acknowledged that nursing staff should have been more proactive in addressing the symptoms, which could indicate infection. A CT head and neck angiography performed at the hospital later showed numerous bilateral dental caries, and the dental consultant stated he would have expected immediate contact from staff upon the resident’s complaint of oral pain and emphasized the need for clear communication from the facility to his office. The resident reported still having pain during a subsequent interview.
Failure to Arrange Requested Dental Services for a Resident
Penalty
Summary
The facility failed to obtain routine dental services when requested for a resident with missing upper teeth. The resident was cognitively intact, had end-stage renal disease, and received regular consistency food with thin liquids, with no documented swallowing disorders, dental problems, or significant weight loss on the MDS. Since admission, there was no evidence in the medical record that the resident had been examined by a dentist, and the active care plan contained no information related to dental care. During observation, the resident was noted to have no upper teeth and reported having two remaining upper back teeth that needed extraction before being fitted for a partial denture. The resident stated that she had requested to see a dentist from several nurses but was told that the dentist’s on-site visits occurred while she was away at dialysis, which was scheduled three times per week. She reported not having seen a dentist since admission, though she had experienced mouth pain in the past from the remaining upper teeth. The Appointment Scheduler explained that residents requesting dental services should be added to a list for the next on-site visit or scheduled for an outside appointment if they could not be seen during on-site hours, and that the facility would arrange transportation. However, the Appointment Scheduler reported she had not been informed by nursing staff of this resident’s requests, and a review of dental appointment records confirmed the resident had not been seen by a dentist and was not on the list for the most recent on-site dental visit.
Failure to Obtain Timely Dental Services After Loss of Denture
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining timely dental services after the loss of an upper denture, contrary to its own Dental Services Policy requiring referral within three days for lost or damaged dentures. The resident, who had dementia and chronic kidney disease, was documented on December 22, 2025, as having a missing upper denture that could not be located despite staff searching her room. Her care plan included an intervention to obtain a dental consult as needed, and there was a physician order allowing dental visits as needed. However, no dental referral was made until January 23, 2026, more than a month after the denture was reported missing, and the resident was not seen by a dentist for an impression for a new upper denture until February 2, 2026. During this period, multiple speech therapy notes documented that the resident had decreased meal intake and difficulty chewing due to the missing denture, leading to a downgrade to a puree diet, which she refused, and then to a mechanical soft diet. The resident repeatedly complained about her inability to chew mechanical soft textures and expressed to staff and family that she disliked the softer diet and wanted dentures so she could eat regular food again. Observations showed her eating without her upper denture, and interviews with the Speech Language Pathologist confirmed that the resident continued to voice a desire for new dentures. Weight records showed a decrease from 191.6 pounds on January 9, 2026, to 184.2 pounds on March 2, 2026, after the denture went missing. The DON stated she would expect residents to receive timely dental consultations for missing dentures.
Failure to Arrange Recommended Dental Extractions and Ongoing Dental Care
Penalty
Summary
Failure to obtain routine and emergency dental services occurred when a cognitively intact resident, admitted in 2020 and discharged in 2026 with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and COPD, did not receive recommended dental treatment or ongoing dental care. A dental exam performed by an outside provider in April 2024 documented a referral for extraction of teeth #3, 8, 9, and 14, and the associated patient referral form specified extractions of those teeth. No additional dental service notes or documentation of completed extractions were found in the facility records after that visit. Email correspondence from the contracted dental provider in February 2026 confirmed that the last notes for this resident were from 2024 and that the resident was not enrolled in the dental program, meaning she would not be seen regularly unless the facility or family submitted a request. Interviews with facility staff further showed that the facility did not follow through on arranging the recommended extractions or ensuring ongoing dental services. The dental provider’s clinical support stated that after the April 2024 exam and recommendation for extractions, they never heard anything further and that it was the facility’s responsibility to take the referral to an outside dental office and schedule care. The Social Services Director stated the resident was on Medicaid and should be scheduled to see a dentist at least yearly, with nursing notifying Social Services when appointments were needed. The DON acknowledged that if the last dental service was in 2024, the resident did not receive dental services for the entire year of 2025. The Assistant Administrator reported that the facility had no dental services policy and procedure regarding frequency of services, and an undated facility document stated residents would be seen on an as-needed basis, while residents’ rights materials stated the facility must provide services to keep residents’ physical and mental health at their highest practicable levels.
Failure to Provide Routine and Follow-Up Dental Services
Penalty
Summary
Facility staff failed to ensure residents received required routine and follow-up dental care, resulting in missed or delayed dental assessments and services. One resident was observed during the initial tour to have few, if any, teeth, and review of the clinical record showed no dental consult in over a year, despite the requirement for at least an annual inspection of the mouth and jaw and diagnosis of any dental disease. When interviewed, the DON confirmed that there was no documentation of a dental consult or examination in the record and that the resident had not been seen by a dentist or dental company since 2023. Another resident with missing teeth and cavities had no clear documentation of routine dental services since admission. The record showed multiple attempted and completed dental encounters: an attempted visit where the resident was not found in the room or hallways, a completed dental exam with notation for a next-visit prophylaxis, and a later attempted dental hygiene encounter that could not be completed due to isolation. There was no documentation that this missed hygiene visit was rescheduled. A change in condition note documented that a left upper molar tooth came out while the resident was talking, with no bleeding or pain noted, and the resident was ordered to be seen by dental services. The last documented dental visit occurred after this tooth loss, and the surveyor identified that the recommended dental hygiene appointment had not been rescheduled following the missed visit.
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