Failure to obtain routine and emergency dental care for a resident with broken carious teeth and mouth pain. The resident had cognitive impairment, was dependent for ADLs, and had oral/dental problems identified on admission, but the dental consult form was blank and no dentist evaluation was documented. The resident later required oxycodone for mouth pain and clindamycin for a tooth abscess, while staff and the DON reported the resident had not been enrolled in the facility dental service and the HCP had not been offered that option.
Failure to Obtain Consent for Denture Fabrication: A cognitively intact resident with no natural teeth reported needing dentures after a dental exam recommended upper and lower dentures to improve eating. The record showed the HCP was activated, but there was no documentation that the resident or HCP signed the required consent form for denture fabrication, and staff acknowledged the consent had not been completed.
A resident with a traumatic brain injury and a court-appointed guardian lost upper and lower partial dentures and was evaluated twice by a dentist, who documented that replacement dentures were needed and instructed staff to obtain the guardian’s signed consent so dentures could be made. Despite these written recommendations and the facility’s policy requiring dental treatment orders and documentation, nursing staff did not secure the required consent, and the medical record contained no evidence of a signed dental consent form. The resident and guardian reported the dentures had been missing for a long time, CNAs confirmed the dentures had been lost for an extended period, and the DON stated she was unaware the dentures were missing, resulting in a prolonged delay in fabricating new dentures.
Failure to Arrange Dental Care After Resident Consent: Three residents with signed dental consents were not assisted in obtaining routine dental services. One resident with DM, HTN, and GERD had tooth pain, an NP referral, and a later dental visit that was blocked by expired insurance, but the record did not show routine dental follow-up. Another resident with dementia and DM requested dental services and dentures but was not placed on the vendor list. A third resident with dysphagia and pulmonary HTN also requested dental care and dentures, but the consent was not followed when the dental vendor was in the facility.
Failure to refer a resident with severe cognitive impairment and total functional dependence for dental care when upper dentures were found broken and lower dentures were missing. Staff, including the nurse, NS, and DON, said they were unaware the dentures were broken and confirmed no dental referral had been made; the chart also lacked documentation of when or how the dentures broke or any dentist notification.
Failure to provide dental services and replace missing dentures. A resident with severe cognitive impairment and dependence on staff was observed eating without dentures, while the resident’s daughter reported the dentures had been missing for about a year. The record showed a dental consult order and consent for dental services, but no evidence the resident was ever seen by a dentist or dental hygienist. Staff, including the unit manager, CNA, social worker, and DON, were unaware of the missing dentures and the lack of dental follow-up; only the lower dentures were found in a labeled container, and the upper dentures could not be located.
Failure to arrange routine dental services for a resident who was cognitively intact and needed assistance with oral care. The resident said staff did not offer routine oral hygiene, was unsure how to schedule a dental cleaning, and was observed with a thick white substance on the gum line. Record review showed no documentation that dental services were offered, accepted, or declined, and staff stated the dental consent form had been missed.
Failure to Provide Routine Dental Services: A resident with dementia, dysphagia, and adult failure to thrive had poor dentition, missing and jagged teeth, and was observed chewing on his/her tongue. The record showed dental care as needed and oral care interventions, but there was no evidence the resident was offered or received routine dental services, and the resident stated the facility would not let him/her see a dentist. The DON and Regional Nurse acknowledged the resident should have had routine dental services in place.
Failure to Provide Routine Dental Services After Consent Was Obtained: A resident with dementia and anxiety, who was dependent on staff for oral hygiene, had dental consent signed by the HCP but there was no evidence of routine dental care for an extended period. The resident later reported tooth pain and difficulty swallowing, staff documented broken teeth and pain, and the resident’s representative said the resident had repeatedly requested dental care but had not been seen by the dentist.
Failure to Provide Recommended Denture Replacement: A resident with heart disease and DM lost upper dentures and a lower partial at the facility and later reported difficulty eating. A dentist recommended new upper and lower dentures and full mouth X-rays after discussing the issue with Social Services and a nurse, but the recommendation was not documented in the medical record or acted on, and staff interviewed were unaware of the dental plan.
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 August 26, 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.