Failure to Ensure Dental Evaluations for Two Residents
Summary
The facility failed to ensure that residents received necessary dental services, resulting in two residents not being evaluated by a dentist after admission. One resident was admitted with multiple diagnoses including a history of TIA, CHF, diabetes mellitus, dementia, and depression. Her care plan, initiated several months after admission, identified that she exhibited or was at risk for oral health or dental care problems due to multiple missing teeth. During an interview and observation, this resident reported she had not been to a dentist since admission, had several missing teeth, and stated that a broken tooth was bothering her, which she had reported to several staff members without resulting in a dental appointment. Her EHR showed only a single dental appointment dated several months after admission, with no further documentation of dental evaluations. Another resident, admitted with type 2 diabetes mellitus, acute CHF, and NSTEMI, stated during interview that she needed to go to the dentist and was observed to have a missing front tooth. Review of her EHR revealed no documentation that she had been evaluated by a dentist since admission. In an interview, the facility Scheduler confirmed that both residents had not been seen by a dentist since admission, despite her stated expectation that all residents have an annual dental appointment. She acknowledged that she attempts to keep up with scheduling annual dental visits for all residents and had missed scheduling for these two residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an infected tooth, severe toothache, and visible decay had provider orders for urgent dental referral and priority scheduling, but the appointment was never arranged or completed. Staff gave conflicting accounts about who handled referrals, and the MRD could not find evidence of a dental visit, a waitlist entry, or a documented refusal. The DON and NP stated the referral should have been followed up timely.
A resident with severe cognitive impairment, stroke-related deficits, and Medicaid coverage reported a pending dental follow-up after being seen for tooth pain. The dental consult documented fractured and hopeless teeth and referred the resident to an oral surgeon for extractions, but an LPN stated the referral was never made.
Failure to arrange routine dental services for a resident with severe cognitive impairment, dysphagia, and dependence for oral hygiene. The resident had missing and broken teeth, and the chart contained no completed dental care or dental assessments. Social work staff stated they were responsible for scheduling dental appointments but could not locate any dental records for the resident.
Failure to provide dental services for a resident with tooth pain and an infected tooth. The resident had a dental consult showing a need for tooth extraction due to infection and a fistula, but the recommended follow-up was not completed. The resident later reported waiting to be seen by a dentist and still having pain. SSD and DON stated social services was expected to follow up with dental recommendations, and the facility policy says social services assists residents with appointments.
Failure to follow up on a resident’s dental referral resulted in no documented completion of x-rays, evaluation for tooth extraction, or referral for new dentures. The resident had mouth/facial pain and difficulty chewing, reported broken and missing teeth, and the care plan directed staff to coordinate dental care and transportation as needed. The DON confirmed there was no documentation of follow-up on the dental consult.
Failure to Provide Dental Services: A resident admitted with ESRD and DM2 was documented as cognitively intact with no dental issues, but later was observed with several broken and missing upper front teeth and reported cavities that made chewing challenging and sometimes painful. Staff interviews showed inconsistent understanding of the resident’s oral care needs, with CNAs saying they only reminded the resident to brush after meals and an LPN unaware of missing teeth or cavities; the DNS later found missing, cracked, and decayed teeth that needed to be addressed.
Failure to Follow Up on Emergency Dental Referral
Penalty
Summary
The facility failed to ensure follow-up for an emergency dental referral for a resident with an infected tooth. The resident’s quarterly MDS indicated he was cognitively intact, needed setup or clean-up assistance with oral hygiene, and required substantial to maximal assistance with transfers and mobility. His diagnoses included ataxia and need for assistance with personal care. A provider visit note documented severe toothache, left upper molar decay with partial breakage, and erythema around the gum line, and the provider placed an order for referral to a dentist for definitive treatment of the infected left upper tooth with priority escalation for scheduling. The next day, another provider order again instructed referral to a dentist for treatment of the infected left upper tooth. During interviews, the resident stated he had a tooth infection and was supposed to see a dentist but never did. Staff gave conflicting accounts about how dental referrals were handled, with the LPN, DON, and MRD identifying the MRD as responsible for scheduling, while the MRD initially stated she thought an appointment had been set up and the resident refused care. The MRD could not locate evidence that the resident was ever seen by the outside dental provider, was on a list to be seen, or had a documented refusal. The outside dental appointment coordinator stated the resident was not enrolled for dental care and had only elected podiatry services. The MRD later stated the resident would have needed an external dental clinic of his choice and that an appointment should have been arranged when originally ordered, but she could not explain why it was missed. The DON and NP stated they expected referrals to be followed up timely and that the resident should have been seen by a dentist by then.
Delayed Oral Surgeon Referral After Dental Consult
Penalty
Summary
The facility failed to ensure a timely dental services referral for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and vascular dementia, and the Quarterly MDS reflected severe cognitive impairment with a BIMS score of 3 out of 15. The resident had Medicaid as the payer source. During observation, the resident stated she had seen the dentist for a problem with a tooth on the lower left side of her mouth and said she was supposed to have a follow-up but had not heard anything yet. The dental consult documented severe pain with pressure in the lower left and some pain in the upper anterior left corner, noted fractured and hopeless teeth, and recommended removal of remaining upper teeth and lower fractured teeth by an oral surgeon, specifically referring the resident for removal of teeth #10, 11, and 18. In interview, an LPN stated the referral to the oral surgeon was never made after the dental appointment.
Failure to Arrange Routine Dental Services
Penalty
Summary
The facility failed to assist Resident #117 in obtaining routine dental care after admission. Resident #117 was a [AGE]-year-old male admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, cognitive communication deficit, and vascular dementia. His quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and he required substantial to maximal assistance with oral and personal hygiene. During observation, he was noted to have missing and broken teeth, and his record did not show any completed dental care or dental assessments. Record review and staff interviews showed the facility could not locate any dental assessments for Resident #117. The social workers stated they were responsible for scheduling dental appointments and were unaware that he had not seen a dentist. The facility policy stated that Social Services coordinates referrals to outside agencies for services not offered by the facility, including dental services, but no completed dental services or assessments were found for this resident.
Failure to Follow Up on Dental Services for a Resident with Tooth Infection
Penalty
Summary
The facility failed to provide dental services for one sampled resident, Resident 198. The resident was admitted with diagnoses including major depressive disorder and hypertension. A dental consult note dated 2/11/2026 documented tooth pain and an infected tooth, and the resident agreed to a tooth extraction. The MDS dated 2/13/2026 showed the resident had moderately impaired cognition and required maximal assistance with toileting, showering, and personal hygiene. During an interview on 4/7/2026, Resident 198 stated she had been waiting to be seen by a dentist after a recent tooth infection and was still having pain. On 4/10/2026, the SSD stated the resident's last dental visit was 2/11/2026 and that the recommendation for tooth extractions due to infections and a fistula was not followed up on, although it should have been. The DON stated the social services department was expected to follow up with dental recommendations, and the facility policy stated routine and emergency dental services are available and social services representatives will assist residents with appointments.
Failure to Follow Up on Dental Referral and Denture Needs
Penalty
Summary
The facility failed to provide dental services for one Medicaid resident who was cognitively intact and had mouth or facial pain, discomfort, and difficulty chewing. The resident reported chipped and cracked lower teeth, stated they had pulled one tooth out the prior week, and said they had no upper teeth and difficulty eating spaghetti. The resident’s care plan, initiated for natural carious and broken teeth with pain and difficulty chewing, directed staff to coordinate dental care and transportation as needed or as ordered. A provider order dated 11/22/2025 directed the resident to receive dental services as needed. A dental consult dated 11/10/2025 documented a referral for x-rays and evaluation for extraction of tooth 18, with a plan to refer the resident for new dentures. The dentist wrote that the resident wanted tooth extraction and new dentures made. Review of the electronic health record showed no documentation that staff followed up on the dental referral for extraction or new dentures, and the DON stated there was no documentation that the referral for x-rays, evaluation, tooth extraction, or dentures had been followed up on.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for one resident who was admitted with diagnoses including end stage renal disease and type 2 diabetes. The resident’s admission MDS indicated cognitive intactness and no missing, cracked, or decayed teeth, and the nursing admission assessment documented no dental issues. The care plan later indicated the resident required constant supervision and physical assistance to complete oral hygiene tasks. During observation, the resident was found to have several broken and missing upper front teeth and stated that most of the upper teeth were missing and that cavities made chewing challenging and sometimes painful. The resident also stated staff never examined the inside of the mouth or asked about dental health. Staff interviews showed differing understandings of the resident’s oral care needs: CNAs reported only reminding the resident to brush after meals, one LPN stated the resident was fairly independent and required set-up assistance, and another LPN was unaware of missing teeth or cavities. The DNS later examined the resident’s dentition and stated the resident had missing, cracked, and decayed teeth that needed to be addressed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
