Delayed Dental Care and Pain Management
Summary
The facility failed to ensure prompt dental services for a resident with vascular dementia, DM II, major depressive disorder, epilepsy, and severe cognitive impairment. The resident was nonverbal and required assistance with ADLs, had a feeding tube and mechanically altered diet, and had been ordered PRN Tylenol for pain. On 06/19/25, the resident spent most of the shift screaming loudly in the common area and could not be redirected. The next day, oral intake decreased, and over the following days meal intake dropped further from prior 100 percent intake to 26 to 50 percent, then 0 to 25 percent, with continued poor intake thereafter. On 06/25/25, nursing documented continued behaviors including not eating, biting her fingers, and spitting out medications, and the resident was started on Augmentin for a presumed tooth infection. The June MAR showed no Tylenol administered for dental pain, and the July MAR showed Tylenol given only once. By 07/07/25, staff reported the resident had not been eating for three weeks due to tooth pain, had lost weight from 142.4 pounds to 134 pounds, and continued to show behaviors such as holding her cheek, biting her thumb, and drooling. On 07/15/25, the resident had lost 10.4 pounds, a 7.3 percent loss in one month, was only eating chocolate chip cookies and taking sips of supplement, and a dental consultation was ordered for oral surgery to extract teeth with severe decay and infection. The dental appointment process was delayed, with an outside dental provider not contacted until 07/15/25 and the consult not scheduled until 10/03/25. In September, the guardian canceled one appointment because the resident would not cooperate without sedation, and later declined to complete consent paperwork at the facility. During observation on 09/23/25, the resident was seen chewing on her fingers and eating less than 50 percent of lunch, and on 09/24/25 her teeth appeared rotten with decay and receding gums. Staff interviews confirmed that CNA, ST, and RD had reported the resident's dental pain and decreased intake, and the NP stated she had not been notified of ongoing dental pain but verified the resident's behaviors were indicative of dental pain.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with no natural teeth, diabetes, HF, and dysphagia remained without dentures despite repeated dental recommendations for new upper and lower dentures and a documented request process. Staff were unsure whether the request had been denied, later learned it had been denied for additional information, and acknowledged the denture issue had not been addressed sooner.
A resident with hydrocephalus and weakness reported mouth pain for months, but dental care was delayed despite repeated complaints to staff. The dentist initially evaluated the resident and planned extractions, but the procedure was postponed because consent was not obtained in time, and the resident was not scheduled for the next dental visit. The facility’s policy required assistance with routine and emergency ancillary services, including urgent dental treatment for pain.
Failure to provide or document routine dental services for a resident with severe cognitive impairment and dependence for all cares, including oral hygiene. The resident had multiple broken teeth on dental consult, but the EMR did not show a follow-up dental visit or evidence that routine dental care was offered or provided. Interviews with the resident’s emergency contact and facility staff showed there was no clear process to track dental visits, refusals, or coordination of routine dental services, and the DON confirmed the record lacked documentation of dental care.
Failure to provide routine dental services for two residents was identified. One resident had broken or likely cavity-affected natural teeth, a dental care plan, and limited dental documentation, but no evidence of twice-yearly professional dental services under the State plan. Another resident was edentulous, reported not being offered a dentist since admission, had ill-fitting dentures at home, and the facility could not produce documentation that dental services were offered despite a care plan noting dental consultation as needed.
A resident voiced concern about a dental appointment for dentures. Record review showed the resident missed the scheduled dental visit because of illness, and the appointment was never rescheduled; the ADON verified this.
Failure to provide timely dental services for a resident with DM, HTN, chronic pain, and malnutrition. The resident had impaired cognition, obvious or likely cavities or broken natural teeth, a loose tooth, and intermittent pain, with an order for dental evaluation and an order for Orajel for tooth and gum pain. Records and staff interview confirmed the resident had not been seen by the dentist since admission, despite the facility policy stating routine and emergency dental services were available.
Delayed Dental Services for Resident Awaiting Dentures
Penalty
Summary
The facility failed to ensure prompt dental services were provided for one resident who was admitted with diagnoses including heart failure, diabetes, and dysphagia and who was able to make needs known. During observation and interview, the resident stated they wanted dentures because they had no teeth and staff were aware, but they still did not have dentures. The resident had no upper or lower teeth and no visible dentures in the room, and the annual MDS confirmed the resident had no natural teeth or tooth fragments. The resident’s care plan documented missing teeth, that upper and lower dentures were not with the resident, and that the resident was waiting for dentures. Dental visit/exam forms dated over multiple visits showed recommendations for new upper and lower dentures, and one form noted the resident said dentures were lost a few weeks earlier and wanted new dentures. A denture request form was signed by the provider and emailed, but staff interviews showed uncertainty about whether the request had been denied and that the issue had not been addressed sooner. Staff later learned the January 2025 request had been denied for needing additional information, and both the RCM/LPN, central supply/transportation staff, and the Administrator stated the denture request should have been addressed sooner.
Delayed Dental Care and Consent Process
Penalty
Summary
The facility failed to ensure timely and necessary dental services for a Medicaid resident who was cognitively intact and had diagnoses including hydrocephalus and weakness. The resident reported mouth pain to staff for months and stated that she first complained of pain in the beginning of March, but she did not see the dentist until the tooth was extracted on April 30, 2026. The facility policy stated that it was to assist residents in obtaining routine and emergency ancillary services as needed, and defined emergency dental services as treatment for pain in teeth, gums, broken or damaged teeth, or any other problem requiring immediate attention by a dentist. An email from the social services director requested a dental evaluation after the resident complained of tooth pain, and the dental services coordinator responded that the resident would be seen 10 days later. At that visit, the dentist noted that the resident requested extraction of two teeth with plus 2 mobility and planned to extract them at the next visit. The dental care coordinator later requested a consent form before scheduling the extraction, and when the social services director asked how consent would be obtained if the resident could not physically sign, the coordinator confirmed verbal consent was acceptable. The resident was not on the schedule for the next dental visit because consent had not been obtained, and the extraction was not scheduled until later after the consent was eventually sent.
Failure to Provide or Document Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided or offered for one resident with significantly impaired cognition who was dependent on staff for all cares, including oral hygiene. The resident had diagnoses including neurocognitive disorder with Lewy body dementia, fibromyalgia, and arthritis. A dental consult noted multiple broken teeth and recommended extraction of any teeth that became symptomatic, but the resident’s EMR did not show evidence of a follow-up dental visit after that consult. The resident’s care plan stated dental appointments were to be based on resident or resident representative preferences. During interviews, the resident’s emergency contact stated he expected the facility to arrange routine dental services and could not recall the last time the resident was seen by a dentist, adding that the resident did not have many teeth left and wanted to be seen. Staff interviews showed the social services department did not coordinate routine dental visits, the nurse manager for the memory care unit was not involved in coordinating them, and the infection control preventionist sent an annual email to family members and guardians asking if they wanted the resident seen by a dentist. The regional director of clinical services stated the facility did not have a process to identify and document refusals or when the last dental visit occurred, and both she and the infection control preventionist stated residents could be missed for routine dental visits. The DON verified the EMR failed to show the resident was offered or provided routine dental visits, and the facility policy stated routine and emergency dental services are provided and all dental services are recorded in the medical record.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for two residents reviewed for dental concerns. Resident 22’s record showed an annual MDS assessment identifying obvious or likely cavity or broken natural teeth, and the dental CAA triggered a care plan. The care plan, initiated on November 13, 2023, included obtaining dental consultation as necessary. The resident’s record contained documentation from the facility’s consultant dentist dated April 10, 2025 and from the consultant dental hygienist dated February 9, 2026, but the DON and NHA stated on May 21, 2026 that there was no further evidence of professional dental services provided twice a year as covered under the State plan for Resident 22. Resident 22’s daughter stated that the resident had bad natural teeth and that she was not opposed to services from the facility’s contracted dental provider. Resident 3 was observed edentulous and stated he had not been offered a dentist since admission. He also stated he had dentures at home that did not fit correctly. The resident was admitted on September 3, 2025, and the admission MDS assessed no obvious or likely cavity or broken natural teeth. The care plan, initiated September 9, 2025, identified risk for altered dentition and/or mucous membranes related to edentulous status and noted that the resident did not wear dentures, with an intervention to obtain dental consultation as necessary. The facility was unable to provide documentation that dental services were offered to Resident 3, and the NHA confirmed these findings.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide dental services for Resident #110. During an interview, the resident expressed concern about having a dental appointment for dentures. Record review showed the resident’s last dental appointment had been scheduled for 01/23/25, but the resident was sick and did not attend. The appointment was never rescheduled, and the ADON verified that it had not been rescheduled.
Failure to Provide Timely Dental Services
Penalty
Summary
Provide or obtain dental services for each resident. The facility failed to ensure timely dental services for one resident reviewed for dental services. Resident #12 was admitted with diagnoses including diabetes mellitus, hypertension, chronic pain, and unspecified protein-calorie malnutrition. The medical record showed a physician order for a dental visit shortly after admission, and later an order for Orajel for tooth and gum pain. The resident’s MDS assessment documented impaired cognition and noted obvious or likely cavities or broken natural teeth. The dental visit record showed the resident had not been seen by the dentist during the period reviewed, including after the order for dental evaluation. During interview, the resident stated she needed to see the dentist, had a loose tooth and pain at times, and required a special diet because of her dental status. The Medical Records Coordinator verified the resident had not been seen by the dentist since admission and stated the facility’s dental service did not do emergency services. The facility policy stated routine and emergency dental services were available and that social services personnel were responsible for assisting the resident or family in making dental appointments.
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