A resident with no upper teeth and multiple missing lower teeth did not have the Social Services Initial Psychosocial Assessment completed, leaving the dental ancillary services section blank. Staff stated there was no dental mobile consult pending, and the DSS, DON, and an LVN acknowledged the resident's dental needs were not identified or followed up through the admission assessment process.
A resident with stroke-related diagnoses and intact decision-making capacity lost his upper dentures in the facility and was charged $800 for replacement. The resident said he filed a grievance after being told to pay for the dentures, while SS confirmed the dentures were listed in his inventory and the facility could not locate them. The DON stated the resident should not have been required to cover the cost because the dentures were misplaced in the facility.
Failure to follow up on recommended dental services for a resident with impaired cognition and assistance needs for oral hygiene. Dental notes documented heavy tartar and recommendations for cleaning, scaling, root planing, and x-rays, while the resident reported something stuck in his teeth and staff were told about the concern. SSD stated the family agreed to pay out-of-pocket for cleaning, the resident had no dental insurance, and the SSD did not follow up on the dental service; QA stated the resident was at risk for pain and reduced food intake leading to weight loss.
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.
Failure to provide timely dental services for a resident with DM2, a below-the-knee amputation, and HTN. The cognitively intact resident requested dental hygiene and evaluation of a broken tooth causing discomfort, but the request was not followed up. The DON said dental visits occurred periodically and referrals were made for concerns, while the SSD confirmed the resident had been in the facility for two months without a baseline dental exam and that a prior dental visit did not include the resident due to insurance coverage issues.
A resident with decision-making capacity reported tooth pain and was seen by the facility dentist, who documented possible retreatment and/or a new crown and noted that an outside dental appointment would be arranged to save the tooth. The resident later stated she still wanted to see her primary dentist for a second opinion and had been waiting months for an appointment, while the SSD confirmed the follow-up dental visit had not been scheduled.
Failure to Arrange Dental Consultation and Treatment: A resident with DM2, anemia, dysphagia, and major depressive disorder had missing and broken teeth, no dentures, and no recent dental visit despite wanting treatment completed and reporting the need for a dental consult. Records showed dental consultation was listed as needed, the care plan identified dental problems, and staff, including the SSD, DPC, and DON, acknowledged the resident was not provided dental services.
A resident with full dentures and a BIMS of 15 was found without a lower denture, and only one denture was seen in a cup. The resident stated the lower denture was broken or missing and reported trouble chewing at times, while a CNA said the missing denture had been noticed and reported to the charge nurse about two weeks earlier. A nurse later stated no report of the missing denture had been received, and the resident ate lunch without dentures.
A resident with intact cognition and a need for setup or clean-up assistance with eating requested teeth and was seen by the dentist, who recommended tooth extractions and new dentures/partials. The SSA later acknowledged there was no follow-up after the dental visit and that she overlooked the resident’s dental needs. The DSD and DON stated social services was responsible for dental scheduling and that the lack of timely follow-up delayed denture fitting.
Failure to follow up on dental treatment after extractions. A resident with RA, enterocolitis, swallowing/nutritional concerns, and moderate cognitive impairment was observed without dentures and stated she wanted them. The dentist recommended full extractions with immediate full dentures, but after extractions were completed, the record showed no documented follow-up with the dental provider regarding denture impressions or denture status. The RDH later noted the resident was missing too many teeth to chew and break down food properly, and the SSM stated she did not follow up after the dental visit.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.