Failure to Provide Ordered and Routine Dental Services
Summary
The facility failed to provide dental services following a physician’s referral and failed to provide routine dental services for 3 residents reviewed for dental care. One resident had been admitted since 8/4/2023 and stated it had been a long time since seeing a dentist. The record showed a physician order on 9/27/2024 to refer the resident to a dentist for severe periodontal disease, with progress notes documenting severe periodontal disease, multiple small broken and eroded tooth roots in the maxilla with large surrounding periapical lucencies on CT scan, and a plan to refer to a dentist and start chlorhexidine rinse BID. When the surveyor requested dental records, the facility could not initially locate them, and the records later provided showed only in-facility dental exams in 2025, without proof of follow-up for the ordered referral. Another resident stated the dentist never showed up 3 or 4 months earlier and that they had never seen a dentist; the record showed admission on 12/4/2023, an order for dental consults as needed, and a care plan noting oral/dental problems and a history of poor oral hygiene. A third resident reported broken teeth and no dental services since admission, and the surveyor observed missing teeth. The record review for that resident failed to reveal any dental evaluation or routine dental services since admission. The facility’s dental policy stated it would assist residents in obtaining routine dental services, defined to include annual oral inspection, diagnosis of dental disease, cleaning, radiographs, and smoothing of broken teeth, but the DON stated that resident had not received an annual oral health assessment or routine dental services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an infected tooth, severe toothache, and visible decay had provider orders for urgent dental referral and priority scheduling, but the appointment was never arranged or completed. Staff gave conflicting accounts about who handled referrals, and the MRD could not find evidence of a dental visit, a waitlist entry, or a documented refusal. The DON and NP stated the referral should have been followed up timely.
A resident with severe cognitive impairment, stroke-related deficits, and Medicaid coverage reported a pending dental follow-up after being seen for tooth pain. The dental consult documented fractured and hopeless teeth and referred the resident to an oral surgeon for extractions, but an LPN stated the referral was never made.
Failure to arrange routine dental services for a resident with severe cognitive impairment, dysphagia, and dependence for oral hygiene. The resident had missing and broken teeth, and the chart contained no completed dental care or dental assessments. Social work staff stated they were responsible for scheduling dental appointments but could not locate any dental records for the resident.
Failure to provide dental services for a resident with tooth pain and an infected tooth. The resident had a dental consult showing a need for tooth extraction due to infection and a fistula, but the recommended follow-up was not completed. The resident later reported waiting to be seen by a dentist and still having pain. SSD and DON stated social services was expected to follow up with dental recommendations, and the facility policy says social services assists residents with appointments.
Failure to Provide Dental Services: A resident admitted with ESRD and DM2 was documented as cognitively intact with no dental issues, but later was observed with several broken and missing upper front teeth and reported cavities that made chewing challenging and sometimes painful. Staff interviews showed inconsistent understanding of the resident’s oral care needs, with CNAs saying they only reminded the resident to brush after meals and an LPN unaware of missing teeth or cavities; the DNS later found missing, cracked, and decayed teeth that needed to be addressed.
A resident with COPD and diabetes reported dentures that did not fit and said they had seen a dentist for new dentures but had not heard anything further. Records showed a dental note recommending new upper and lower dentures and extractions, and another note stating the resident needed referral out for x-rays and extractions for all lower teeth. Staff interviews showed the transportation specialist had not seen the denture recommendation and believed only a recall exam was scheduled, while the unit care coordinator had not received notice that the follow-up was completed.
Failure to Follow Up on Emergency Dental Referral
Penalty
Summary
The facility failed to ensure follow-up for an emergency dental referral for a resident with an infected tooth. The resident’s quarterly MDS indicated he was cognitively intact, needed setup or clean-up assistance with oral hygiene, and required substantial to maximal assistance with transfers and mobility. His diagnoses included ataxia and need for assistance with personal care. A provider visit note documented severe toothache, left upper molar decay with partial breakage, and erythema around the gum line, and the provider placed an order for referral to a dentist for definitive treatment of the infected left upper tooth with priority escalation for scheduling. The next day, another provider order again instructed referral to a dentist for treatment of the infected left upper tooth. During interviews, the resident stated he had a tooth infection and was supposed to see a dentist but never did. Staff gave conflicting accounts about how dental referrals were handled, with the LPN, DON, and MRD identifying the MRD as responsible for scheduling, while the MRD initially stated she thought an appointment had been set up and the resident refused care. The MRD could not locate evidence that the resident was ever seen by the outside dental provider, was on a list to be seen, or had a documented refusal. The outside dental appointment coordinator stated the resident was not enrolled for dental care and had only elected podiatry services. The MRD later stated the resident would have needed an external dental clinic of his choice and that an appointment should have been arranged when originally ordered, but she could not explain why it was missed. The DON and NP stated they expected referrals to be followed up timely and that the resident should have been seen by a dentist by then.
Delayed Oral Surgeon Referral After Dental Consult
Penalty
Summary
The facility failed to ensure a timely dental services referral for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and vascular dementia, and the Quarterly MDS reflected severe cognitive impairment with a BIMS score of 3 out of 15. The resident had Medicaid as the payer source. During observation, the resident stated she had seen the dentist for a problem with a tooth on the lower left side of her mouth and said she was supposed to have a follow-up but had not heard anything yet. The dental consult documented severe pain with pressure in the lower left and some pain in the upper anterior left corner, noted fractured and hopeless teeth, and recommended removal of remaining upper teeth and lower fractured teeth by an oral surgeon, specifically referring the resident for removal of teeth #10, 11, and 18. In interview, an LPN stated the referral to the oral surgeon was never made after the dental appointment.
Failure to Arrange Routine Dental Services
Penalty
Summary
The facility failed to assist Resident #117 in obtaining routine dental care after admission. Resident #117 was a [AGE]-year-old male admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, cognitive communication deficit, and vascular dementia. His quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and he required substantial to maximal assistance with oral and personal hygiene. During observation, he was noted to have missing and broken teeth, and his record did not show any completed dental care or dental assessments. Record review and staff interviews showed the facility could not locate any dental assessments for Resident #117. The social workers stated they were responsible for scheduling dental appointments and were unaware that he had not seen a dentist. The facility policy stated that Social Services coordinates referrals to outside agencies for services not offered by the facility, including dental services, but no completed dental services or assessments were found for this resident.
Failure to Follow Up on Dental Services for a Resident with Tooth Infection
Penalty
Summary
The facility failed to provide dental services for one sampled resident, Resident 198. The resident was admitted with diagnoses including major depressive disorder and hypertension. A dental consult note dated 2/11/2026 documented tooth pain and an infected tooth, and the resident agreed to a tooth extraction. The MDS dated 2/13/2026 showed the resident had moderately impaired cognition and required maximal assistance with toileting, showering, and personal hygiene. During an interview on 4/7/2026, Resident 198 stated she had been waiting to be seen by a dentist after a recent tooth infection and was still having pain. On 4/10/2026, the SSD stated the resident's last dental visit was 2/11/2026 and that the recommendation for tooth extractions due to infections and a fistula was not followed up on, although it should have been. The DON stated the social services department was expected to follow up with dental recommendations, and the facility policy stated routine and emergency dental services are available and social services representatives will assist residents with appointments.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one resident who was admitted with diagnoses including end stage renal disease and type 2 diabetes. The resident’s admission MDS indicated cognitive intactness and no missing, cracked, or decayed teeth, and the nursing admission assessment documented no dental issues. The care plan later indicated the resident required constant supervision and physical assistance to complete oral hygiene tasks. During observation, the resident was found to have several broken and missing upper front teeth and stated that most of the upper teeth were missing and that cavities made chewing challenging and sometimes painful. The resident also stated staff never examined the inside of the mouth or asked about dental health. Staff interviews showed differing understandings of the resident’s oral care needs: CNAs reported only reminding the resident to brush after meals, one LPN stated the resident was fairly independent and required set-up assistance, and another LPN was unaware of missing teeth or cavities. The DNS later examined the resident’s dentition and stated the resident had missing, cracked, and decayed teeth that needed to be addressed.
Failure to Provide Needed Dental Services
Penalty
Summary
The facility failed to provide needed dental services for Resident 17, who was admitted with COPD and diabetes and was able to make needs known. The resident stated during interview that their dentures did not fit and that they had seen a dentist three months earlier for new dentures but had not heard anything further. The EHR included a Dental Progress Note dated 02/05/2026 recommending new upper and lower dentures and extractions, and a progress note dated 02/12/2026 stating the resident was seen by an outside dental provider and would need a referral out for x-rays and extractions for all lower teeth. Staff interviews showed the transportation specialist had not seen the recommendation for new dentures and believed the resident was only scheduled for a recall exam in one year, while the unit care coordinator stated transportation was expected to schedule the follow-up and notify them when completed, but no notice had been received.
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