Failure to Arrange Needed Dental Follow-Up and Oral Surgery Referral
Summary
The facility failed to ensure that a resident received needed dental services as required by regulation and facility policy. The resident, who was cognitively intact and admitted with diagnoses including COPD, heart failure, type 2 diabetes mellitus, hypothyroidism, and major depressive disorder, had a care plan identifying potential for oral/dental health problems due to poor oral hygiene, with interventions to coordinate dental care and monitor for oral problems. A dental visit in July 2025 documented an initial exam, cleaning, full mouth x-ray, and a note for a possible oral surgeon referral. The resident reported that a few months after admission she met with the dentist and was told she would be notified when the dentist returned, but she was never notified of a return visit or a follow-up appointment. Despite the dentist returning to the facility in December 2025, the resident was not placed on the list to be seen, and the social services staff member interviewed could not explain why the resident was omitted. The resident reported ongoing concerns with her teeth and stated she needed four teeth removed by an oral surgeon, but no appointment had been scheduled. She also verified that she had requested Tylenol to help alleviate tooth pain. Facility policies stated that residents shall be offered dental services as needed and that routine and emergency dental services are available in accordance with the assessment and care plan, with social services responsible for assisting with appointments and transportation, but these processes were not carried out for this resident.
Plan Of Correction
F791 Dental Services The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #34 has been scheduled by social worker on3-26-2026 for the closest dental care in an acute care setting as referred by her dentist. Resident refused on 3-26 2026 to go to the setting scheduled and wants to wait until next visit by the dentist in the facility The social Worked placed resident on the list for next dental visit. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents residing in the facility have a potential need for dental care. A sweep of the facility residents to determine any residents needing dental care was done by interviews chart review and the dentist list. scheduled revealed that residents have been scheduled to see the dentist. except for those who have refused in the past. Those residents who have refused in the past. Those residents have been offered to schedule a visit. Completed 4-7-26 per SW. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Administrator conducted an in-service for the social worker on 3-17-26 to include need to timely find dental services as needed for the residents and what is available for the residents needing routine dental care. How the corrective action will be monitored to ensure the deficient practice will not recur. Weekly audit began 4-7-2026 of new admissions and any residents requesting needing dental services or complaining of dental pain to ensure all residents are scheduled for dental care per social services X 2 months.Results submitted to QAPI committee.Concerns identified are immediatly resolved and reeducation of staff completed by social worker/administrator.
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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