Oral Surgery Cancelled After Medication Hold Order Was Not Transcribed
Summary
The facility failed to ensure an order for oral surgery was transcribed timely and followed timely for one resident who was scheduled for oral extractions. The resident had diagnoses including dementia, major depressive disorder, morbid obesity, congestive heart failure, and type 2 diabetes mellitus. A pre-surgical instruction sheet from the oral surgery center indicated the facility was to hold the resident’s scheduled doses of Jardiance four days before the procedure, and the resident had a current physician’s order for Jardiance 10 mg daily. Review of the March 2026 MAR showed the resident received Jardiance on March 21, 22, 23, and 24. A nursing note documented that the oral extractions were cancelled because the Jardiance had not been held prior to the procedure. The Unit Manager stated the facility had received a fax from the oral surgery center with instructions to hold Jardiance, but those orders had not been transcribed into the resident’s EMR. The Regional Nurse Consultant stated the facility did not have a policy for following physician’s orders.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with no natural teeth, dysphagia, and chewing/swallowing difficulty did not receive prompt dental services, and the oral health care plan did not match the resident’s current status. Staff said the dental referral was sent late, the dentist was in the facility but the resident was not seen, and the DON stated the need for dentures should have been addressed sooner.
A resident with COPD, dementia, anxiety, nicotine dependence, and a prior cerebral infarction remained edentulous and waited over a year for dentures. The care plan identified oral/dental risk, and progress notes showed repeated staff and NP follow-up with the dental clinic, but the resident still had not received dentures and continued to report concern about the delay. Staff interviews confirmed the resident was still without dentures and that the issue had been reported for follow-up.
Failure to Provide or Document Routine Dental Services: A resident with dementia and anxiety who needed help with oral hygiene had no EMR evidence of a dental referral, consult, or documented routine dental visit. Staff and leadership stated the facility’s annual dental process was handled inconsistently, with no reliable way to track refusals or the last dental visit, and the resident and guardian were unaware of when dental care last occurred.
Failure to provide ordered dentures to a resident. The resident reported being fitted for full upper and lower dentures but never receiving them, and said staff did not follow up. Dental consults documented the resident’s request for dentures and later recommended full upper and lower dentures, while the NHA confirmed the dentures were made but not released because of a payment dispute.
The facility failed to ensure timely dental evaluation and treatment for two residents. One resident had a broken front tooth reported by family, but staff documented conflicting assessments and no clear dental referral or follow-up. Another resident was missing upper dentures for an extended period; the diet was not promptly adjusted, impressions were delayed, and the resident was observed eating regular food without dentures and reporting difficulty chewing.
A resident with dental caries, CHF, COPD, anxiety, and mild cognitive impairment had repeated dental consults showing worsening decay and recommendations for restorations, then extractions, but nursing notes did not document the visits, the DON/ADON did not timely review and act on the consults, and the resident’s representative was not promptly notified of findings or refusals. The resident later refused extractions and an attempted restoration, and the representative stated he or she was not informed of the earlier dental recommendations or delays in care.
Delayed Dental Care and Inaccurate Oral Health Care Plan
Penalty
Summary
The facility failed to provide prompt dental care services and failed to ensure the care plan reflected the resident’s current dental status for one resident who was admitted with respiratory failure, generalized muscle weakness, and dysphagia. The resident was able to make needs known and stated in interview that they had no dentures and would not mind getting dentures, and that staff had not asked whether they wanted dentures. The admission MDS showed the resident had no natural teeth or tooth fragments, and a focused oral health care plan created later listed broken/missing teeth with interventions to brush and clean dentures and encourage brushing teeth and gums. The resident’s provider progress note documented that the resident was edentulous with chewing and swallowing difficulties. Staff interviews showed an internal referral for dental services was sent on 05/18/2026, but staff acknowledged it should have been made sooner. The Social Services Assistant stated the email request was forwarded to the Social Services Director the next day, and the Social Services Director stated the dentist was in the facility on 05/19/2026 but the resident was not seen, even though the resident should have been seen then. The DON stated the resident needed to be seen by a dentist for dentures and that this should have been addressed sooner, and also stated the care plan needed revision to reflect the resident’s current oral/dental status.
Delayed Dental Services for Denture Provision
Penalty
Summary
The facility failed to provide timely dental services for a resident who was edentulous and waiting for dentures. The resident had diagnoses including COPD, unspecified dementia, unspecified anxiety disorder, nicotine dependence, and unspecified cerebral infarction, and the most recent MDS showed moderately impaired cognition, verbal and self-directed behaviors, occasional rejection of care, and no wandering. The care plan identified oral/dental health risk related to edentulous status and noted the resident had refused a scheduled appointment to obtain dentures. Progress notes showed the resident repeatedly reported waiting for dentures, with nursing and the NP documenting ongoing concern and requests for staff to follow up with the dental clinic. The record also showed repeated delays and incomplete coordination around the dentures over an extended period. Nursing contacted the clinic and was told the dentures were not yet available and would be mailed to the facility, while later notes documented that the resident was still waiting and wanted to see a dentist regarding dentures. The resident stated he had been trying for over a year to get dentures and had already had impressions made. Staff interviews confirmed the resident remained edentulous, that the concern had been reported to social services, and that the NP had repeatedly raised the issue during wellness visits. The facility policy stated routine dental services were provided through community dentists and social services assisted residents with dental appointments.
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 impaired cognition who required assistance with oral hygiene. The resident had diagnoses of dementia and anxiety, and the annual MDS identified the need for help with oral hygiene. Physician orders dated 7/22/25 included dental consults to evaluate and treat as indicated, and the care plan noted the resident needed assistance with dental care due to dementia and that she had an upper partial denture. The resident’s EMR did not contain a progress note, referral, or documentation of a dental consultation. During observation, the resident was sitting in a wheelchair in her room on the locked memory care unit and had intact teeth in the upper and lower jaw; she stated she did not have dentures, staff had not asked her about dental appointments, and she could not recall the last time she visited a dentist. Interviews with SS, RN, RC, IP, the resident’s guardian, and the DON confirmed the facility had no reliable process to identify, document, or track routine dental visits or refusals, and the DON verified the record did not show that the resident was offered or provided routine dental visits.
Failure to Provide Ordered Dentures
Penalty
Summary
The facility failed to provide dentures to one resident who had been fitted for full upper and full lower dentures. The resident stated that he had been fitted for dentures the prior year but had not received them, and that no facility staff had followed up with him about the dentures. He also stated that without any teeth he talked funny and had difficulty eating some foods. The resident’s care plan addressed oral/dental health problems related to possible broken or carious teeth, and his physician orders included a regular texture diet with thin liquids. Facility records showed a dental consult note indicating the resident wanted full upper and full lower dentures and that full mouth x-rays and lower impressions had been done. Another dental consult later recommended full upper and full lower dentures, and a nursing progress note stated the resident had been seen by Dental Services with no new orders and a recommendation for full upper and lower dentures. The Nursing Home Administrator confirmed that the dentures had been made, but the company would not release them because of an alleged balance due, and the dentures were not delivered to the resident because of the ongoing dispute.
Delayed Dental Evaluation and Denture Follow-Up
Penalty
Summary
The facility failed to ensure routine and emergency dental services were provided for two residents, including assistance in obtaining dental evaluation and treatment. One resident was found by family to have a broken front tooth with exposed roots and several cracked teeth, but there was no documented dental referral or dental follow-up after the concern was raised. The resident had dementia and was documented as usually understood and usually understanding others, yet the grievance record and nursing documentation reflected conflicting findings about whether the tooth was cracked, and no additional dental consultation was documented after the initial dental exam months earlier. A second resident was reported to have missing upper dentures, and the resident remained without the dentures for an extended period. The resident was admitted with atrial fibrillation, hypo-osmolality, hyponatremia, and depression, and the MDS documented intact cognition for daily living decisions. A missing-item report documented the dentures were missing, and a dental consult later noted evaluation for lost full upper dentures with diet adjustment as needed. However, the resident’s diet was not adjusted until several days after the missing dentures were identified, and the full upper denture impressions were not completed until weeks later. During this time, the resident reported difficulty chewing the food served, including uncut roast beef, and stated they wanted ground meat until the dentures were restored. Survey observations and interviews showed the resident without upper dentures while eating a regular meal, and staff statements indicated the dentures had been missing for months. Staff also described delays and uncertainty in the denture process, including waiting for insurance approval and not completing impressions at the first dental visit for the missing dentures. For the resident with the broken tooth, family reported the tooth was chipped and painful, but staff assessments documented no visible crack or sharp edges and there was no documented dental consult after the concern was raised. The facility policy required timely identification, referral, and documentation of dental needs, but the records and interviews showed these dental needs were not promptly addressed.
Failure to Coordinate and Document Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for one resident by not reviewing and acting on in-house dental consult recommendations, not coordinating recommended community dental appointments, not documenting follow-up actions, and not timely notifying the resident’s representative of dental findings and refusals of recommended care. The resident had diagnoses including dental caries, mild cognitive impairment, CHF, COPD, depressive episodes, and anxiety disorder. The quarterly MDS identified intact cognition with a BIMS score of 13 and independence with oral and personal hygiene, transfers, and ambulation. The care plan noted a history of oral/dental problems, dental caries, and ADL deficits related to generalized weakness and recent hospitalization. A dental consult identified decay and fracture of tooth #9, root caries, plaque on and under the partial, and the need for greatly improved oral hygiene, with referral for large restorations to teeth #9, #20, #21, and #29. Review of nursing notes failed to show documentation of the dental visit, notification of the resident’s representative, or any attempt to arrange the recommended outside dental appointment. A later dental consult noted the recommended restorations had not been completed and again directed referral for restorations to the same teeth, but nursing notes again lacked documentation of the visit, representative notification, or appointment coordination. Subsequent dental findings showed progression to moderate decay of tooth #8 and non-restorable decay of teeth #9 and #29, with deep decay and sensitivity in teeth #20 and #21, leading to recommendations for extractions of teeth #9, #20, #21, and #29. The resident refused the extractions at that time, and a later attempt to restore tooth #8 was unsuccessful because the resident refused anesthesia and pulled away. Nursing notes did not document the dental visits or the refusals, and the resident’s representative was not notified until a late entry note documented contact 27 days after the last dental visit. The representative stated he or she was not informed of the earlier dental visits or recommendations and could have helped with attendance and appointments if notified.
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