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:
Failure to Provide Timely Dental Services: A resident with dysphagia and HTN, who was cognitively intact and on Medicaid, had dental impressions taken for complete upper and lower dentures but then had no further documented follow-up with the dentist. The resident reported waiting a long time for dentures, had not received updates, and had not seen the dentist recently; the record showed no further communication after the initial dental consult and impressions.
Incomplete policy for lost dentures: The facility failed to have a complete Dental Services policy addressing when it was responsible for replacing lost or broken dentures. A resident with intact cognition and a history including paraplegia, psychoactive substance abuse, MDD, and anxiety reported that staff removed the upper dentures, placed them on the bedside table, and the dentures later went missing after room cleaning. The resident’s care plan did not address denture storage or cleaning, and the Administrator confirmed the policy lacked a facility-specific protocol for lost or broken dentures.
Failure to provide routine dental services affected two residents. One resident with multiple neurologic and psychiatric diagnoses had documented oral/dental problems, but the record showed no dental visits for over a year and the DON confirmed no dental services since the last recorded exam. Another resident with diabetes, PVD, kidney disease, chronic pain, and anxiety had missing teeth and bone loss; after refusing the facility clinic dentist, there were no documented follow-up attempts to secure outside dental care, and staff interviews showed delays and missed scheduling opportunities.
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.
Failure to ensure timely dental follow-up for a resident with painful teeth. The resident had multiple bottom front teeth visible at the gumline and reported tooth pain; he had been seen by a dentist and was supposed to have extractions, but the treatment had not occurred months later. SS stated the resident wanted extractions only, and the facility did not have a process for ensuring needed dental treatment was completed.
A resident with type 2 DM and CHF reported not having dentures and said they had requested dentures several times. The clinical record showed no evidence that the facility arranged or followed up on dental services for a dental assessment or dentures, and the DSS confirmed there was no documentation of any further dental consults.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely and necessary dental services for one Medicaid resident, Resident 13, out of 27 residents reviewed. The resident was admitted with diagnoses including dysphagia and hypertension, and a quarterly MDS dated April 5, 2026 showed the resident was cognitively intact with a BIMS score of 15. The facility’s Dental Services policy stated that it was the facility’s policy to assist residents in obtaining routine and emergency ancillary services as needed, including annual oral cavity inspection, diagnosis of dental disease, x-rays as needed, dental cleaning, and limited prosthodontic procedures such as impressions for dentures and fitting dentures. Resident 13 stated during interview that she had been waiting to receive dentures, had completed impressions a long time ago, had not received information about when the dentures would be available, and had not seen the dentist recently. The dental consult sheet showed the resident was seen on January 30, 2026 for a comprehensive exam, full mouth x-rays, and impressions and bite registration for complete upper and lower dentures. A later dental consult sheet dated March 30, 2026 indicated the resident was not seen because she was out of the facility in the hospital. The clinical record contained no further communication with the dentist regarding the dentures, and the resident had not been seen by the dentist since the impressions were obtained in January 2026.
Incomplete policy for lost dentures
Penalty
Summary
The facility failed to have a complete policy addressing when it was responsible for replacing lost or missing dentures. Review of the record for one resident showed an admission date of 06/07/24, diagnoses including paraplegia, psychoactive substance abuse, major depressive disorder, and anxiety, and an MDS assessment indicating intact cognition. The resident’s care plan identified oral and dental health problems, but it did not address that the resident had dentures or include interventions for cleaning the dentures and a safe place for storage. The resident stated that on or around the evening of 05/23/26, staff removed the upper dentures and placed them on the bedside table before the resident fell asleep. While the resident was resting, an unknown staff member entered the room and cleaned it, and when the resident awoke, the upper dentures were missing. The resident reported the missing dentures to the Administrator, and after an extensive search the facility could not locate them. The Administrator confirmed the resident reported the dentures missing, staff searched the room without finding them, and the facility contacted the dental office for a replacement quote. The Administrator also confirmed the facility’s Dental Services policy did not specify the protocol for lost or broken dentures when the facility was responsible, and the policy contained a blank section instructing staff to insert the facility-specific protocol.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided to two sampled residents. Resident #12 had diagnoses including unspecified cerebrovascular disease, chronic pulmonary embolism, paranoid schizophrenia, mild vascular dementia with psychotic disturbance, and unspecified seizures. The care plan identified oral/dental health problems related to missing teeth and a history of mouth pain, with interventions to coordinate dental care and transportation, observe and report dental problems, and encourage mouth care twice daily. However, the record contained no progress notes for dental visits in the last 12 months, and the dental treatment record showed the last dental examinations were on 07/20/22, 01/31/23, and 03/20/24. During interview, Resident #12 stated she could not remember the last time she saw a dentist and reported difficulty chewing, and the DON verified the resident had not had dental services since 03/20/24. Resident #55 had diagnoses including Type II Diabetes, peripheral vascular disease, unspecified kidney disease, chronic pain syndrome, and unspecified anxiety disorder. The care plan identified oral/dental problems due to missing teeth and included coordinating appointments and transportation for dental care, observing and reporting dental concerns, and encouraging mouth care twice daily. The resident had a dental examination through the facility clinic on 11/05/25, which noted multiple missing teeth, existing restorations, and moderate bone loss, but the recommendations were illegible. On 04/02/26, Resident #55 refused dental services through the facility clinic, and there were no additional notes showing attempts to schedule dental services. The resident stated he had been trying for months to get an outside dental appointment and was told the only local dentist accepting Medicaid was booked for five months. Staff interviews confirmed the resident did not want the facility clinic dentist, that outside appointments were handled by Medical Records, and that Medical Records did not become aware of the need for an outside appointment until the resident asked at the beginning of June 2026; the first provider contacted had no June availability, and no first-available appointment was scheduled at that time.
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.
Failure to Ensure Timely Dental Follow-Up
Penalty
Summary
Provide or obtain dental services for each resident was not ensured for one sampled resident, Resident 5. During observation on 6/16/26, Resident 5 had multiple bottom front teeth visible at the gumline and stated that his teeth hurt. Resident 5 also stated he had been seen by a dentist at the facility and was supposed to have the teeth removed, but the dentist had not returned. Resident 5's BIMS score dated 5/26/26 was 12. Record review and staff interview showed Resident 5 was admitted on 8/25/25 and had a dental exam in January 2026. Social Services stated the exam notes indicated Resident 5 had discomfort, did not want dentures, and only wanted extractions. On 6/17/26, Social Services stated it had been approximately five months since the dental visit and Resident 5 had not received the dental treatment. Social Services also stated the facility did not have a process for ensuring residents receive needed dental treatment. The facility policy stated routine and emergency dental services are available and that social services representatives will assist residents with appointments, transportation arrangements, and reimbursement of dental services.
Failure to Arrange Dental Assessment for Requested Dentures
Penalty
Summary
The facility failed to ensure that a resident was assessed by a dentist for dentures after the resident repeatedly requested them. Resident R164 was admitted with diagnoses of type 2 diabetes and congestive heart failure. During an interview, the resident stated that they did not have dentures and had requested dentures several times. Review of the clinical record showed no evidence that the facility arranged for or followed up on dental services to obtain dentures after the request. The Director of Social Services confirmed that there was no documentation of any further dental consults for the resident.
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