Failure to Provide Needed Dental Care Resulting in Pain and Severe Weight Loss
Summary
The facility failed to provide or obtain necessary dental care for a resident over a nine-month period, despite clear evidence of multiple broken teeth requiring extraction. The resident, who had Huntington's Disease and a cognitive communication deficit, was not on hospice or an end-stage diagnosis. Initial assessments documented obvious cavities and broken teeth, and the care plan identified poor dental status as a contributing factor to altered nutrition and hydration. Despite this, the resident did not receive timely dental interventions, and referrals to both external and in-house dental providers were either not completed or not followed up effectively. The facility's own dental provider visited multiple times, but the resident was not seen during these visits. During this period, the resident experienced ongoing dental pain, as confirmed by direct interviews and observations, and suffered severe, unplanned weight loss exceeding 20% over six months and 24% over nine months. Staff interviews revealed that oral pain was observed during care, but documentation of pain and physician notification was lacking. The resident's pain and difficulty eating were corroborated by both the resident and staff, yet there was no evidence of consistent or effective follow-up to address these issues. The care plan called for therapy evaluations as indicated, but a speech therapy assessment was not ordered until after surveyor intervention. Attempts to arrange for dental extractions through an oral surgeon were documented in a separate notebook rather than the medical record, and most attempts consisted of leaving messages without successful contact for months. Additional efforts to find alternative providers were limited and ceased after initial refusals. The facility's leadership acknowledged that the resident should have been included in the routine dental program and that documentation and follow-up were insufficient. The resident's physician was not notified of the dental pain, and there was no evidence of pain management or timely dental intervention documented in the medical record.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Failure to address a resident’s denture needs. A resident with damaged lower teeth and no upper teeth stated their upper denture was at home, but the denture need was not included in the care plan. The MDS identified the resident as edentulous, and the nutritional assessment noted missing teeth, absent dentures, and risk for altered nutrition/hydration status related to missing teeth. An RCM/LPN and the Regional Director of QA both stated the resident’s dental needs should have been included in the plan of care and that the resident should have been referred for new 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.
A resident with type 2 DM, ESRD, and dependence for oral hygiene and most ADLs was not scheduled for routine dental care despite facility policy requiring assistance in obtaining such services. The resident reported never seeing a dentist since admission and complained of poor dental condition. An LVN noted decomposed teeth and bad breath, and an RD at the HD center observed rotten lower teeth and foul breath, with the resident again stating no dental visit had occurred. The SSD acknowledged that the on-site dentist could not see the resident because HD appointments conflicted with dental clinic days and admitted she had not arranged a visit on a non-dialysis day, resulting in the resident not receiving needed dental services.
A resident with severe cognitive impairment and a history of stroke experienced prolonged delays in receiving a needed tooth extraction despite repeated reports of dental issues and pain. Over several months, staff documented family complaints of tooth and gum pain, a dentist’s finding of a large cavity in tooth #6 requiring extraction, and multiple attempts to obtain and transmit medical clearance, schedule and reschedule appointments, and confirm receipt of paperwork with the community dental office. An appointment was cancelled due to weather, follow‑up calls often went unanswered, medical clearance review by the dental provider was repeatedly delayed, and the oral surgeon’s limited availability further postponed care. The family member reported ongoing requests and frustration with the lack of timely follow‑up, and both the SSD and DON later acknowledged that the resident’s dental care and extraction were not provided in a timely manner.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Failure to Address Resident Denture Needs
Penalty
Summary
The facility failed to ensure that Resident 35 had dental devices available to improve the ability to eat. Resident 35 was admitted with diagnoses including spondylosis with myelopathy, metabolic encephalopathy, and repeated falls, and was able to make needs known. During observation, Resident 35 had damaged lower teeth and no upper teeth, and stated they used an upper denture that was at home. The MDS identified the resident as edentulous, and the nutritional assessment noted missing teeth, dentures that were not present, and risk for altered nutrition/hydration status related to missing teeth. The care plan initiated on 02/12/2026 did not include a focus area or interventions for dental or denture use. During interview, the RCM/LPN stated the resident used upper dentures but this was not included in the plan of care, and the facility should have reached out to obtain the denture or referred the resident for a new one if it could not be obtained. The Regional Director of QA stated residents were assessed for dental needs on admission, quarterly, and as needed, and that residents with dental needs should have a dental plan of care; the director also stated Resident 35's dental needs should have been included in the plan of care and the resident should have been referred for new dentures.
Failure to Follow Up on Dental Needs and Denture Fitting
Penalty
Summary
The facility failed to follow up on a resident’s request for dentures after the resident was seen by the dentist and the dentist recommended new dentures/partials and tooth extractions. Resident 80 was admitted on 8/3/2021 and readmitted on 8/16/2023 with diagnoses including morbid obesity, type 2 DM, and disease of spleen. The resident’s H&P dated 12/5/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 2/23/2026 indicated the resident could make self-understood and understand others, had intact cognition, and needed setup or clean-up assistance with eating. The record showed an order for dental consultation as needed, and an Onsite Mobile Dental form dated 11/21/2025 documented that the resident wanted teeth and that the dentist recommended teeth extractions and new dentures/partials. A later OMB form dated 12/12/2025 documented 12 PA x-rays but did not include a patient chief complaint or treatment recommendations. During interview and record review, the SSA stated there was no follow up after the 12/12/2025 dental visit and that she overlooked the resident’s dental needs. The DSD stated social services was responsible for scheduling dental services, that the SSA should have followed up the extraction and x-ray results to facilitate denture fitting, and that it was not appropriate to wait four months for denture fitting. The DON stated the SSA should have followed up within the same month the x-rays were done.
Failure to Follow Up on Dental Treatment After Extractions
Penalty
Summary
The facility failed to ensure dental care services and follow-up treatment were provided for one resident who needed dentures after tooth extractions. The resident was observed with only a few remaining teeth in the front of the mouth and no teeth or dentures in the upper or lower posterior gums, and stated she did not have dentures and wanted them. Her record showed diagnoses including rheumatoid arthritis and enterocolitis, a nursing admission assessment noting own teeth, an MDS indicating swallowing/nutritional concerns with food held in the mouth and residual food after meals, and later MDS documentation showing broken or loosely fitting dentures and moderate cognitive impairment. The dental record showed the dentist recommended extraction of upper and lower teeth with full upper and lower dentures and immediate dentures, and the resident agreed to treatment. The dentist documented extraction of teeth 23, 24, and 25, but the record contained no documented evidence that the status of the resident's dentures was followed up with the dental provider after the extraction. The RDH later documented missing teeth in the upper and lower mouth and stated the resident was missing too many teeth to chew and break down food properly to swallow safely. The Social Services Manager stated she did not follow up with the dentist after the extraction and that the resident waited 9 months for dentures.
Failure to Arrange Routine Dental Services for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental services as required by its policy. The resident was admitted with diagnoses including type 2 diabetes mellitus and end-stage renal disease and had fluctuating capacity to understand and make decisions per the History and Physical. The MDS assessment showed the resident could understand and be understood, but required maximal assistance for eating and was dependent for oral hygiene and most activities of daily living, including personal hygiene. Despite these needs, the resident reported not having seen a dentist since admission, and staff interviews and record review did not show that a dental visit had been arranged. During interviews, the resident stated he had not seen a dentist since admission and that his teeth were in bad condition. An LVN reported that the resident came to the facility with decomposed teeth and bad breath and did not know if the resident had been seen by a dentist while in the facility. A renal RD who saw the resident at the hemodialysis center observed rotten lower teeth and foul breath and was told by the resident that he had not seen a dentist since admission. The Social Services Director acknowledged that the dentist could not see the resident during on-site visits because the resident was out for hemodialysis and admitted she should have scheduled the dental visit on a non-dialysis day. The facility’s dental services policy stated that every resident would receive or refuse necessary dental services, including routine care, and that the facility would assist residents in obtaining routine dental care from a licensed dentist, which did not occur for this resident.
Delayed Dental Extraction and Untimely Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely routine and 24‑hour emergency dental care for one resident with a decaying tooth. The resident was admitted with a history of stroke and had a BIMS score of 5/15, indicating severe cognitive impairment. The care plan called for daily oral care and dental visits as needed. On 12/01/25, a family member reported the resident was complaining of tooth and gum pain, with a dentist having recently diagnosed receding gums and a tooth with an exposed root. The physician ordered a repeat dental consult and PRN Orajel. On 12/03/25, staff attempted to schedule a dental appointment, leaving a voicemail when the dental office did not answer. On 12/11/25, the resident attended a dental appointment where tooth #6 was found to have a large cavity requiring extraction, and the dentist requested medical clearance prior to the procedure. On 12/22/25, the resident was seen by the MD for medical clearance, and the facility contacted the dental office to clarify whether Plavix and aspirin needed to be held, leaving a voicemail. On 01/23/26, the dental office cancelled a scheduled appointment due to inclement weather, and attempts to reach the family member were unsuccessful. On 01/27/26, staff called the dental office to reschedule and were informed that completed medical clearance forms had to be faxed before an appointment could be made; the forms were faxed, but follow‑up calls to confirm receipt were not answered. On 01/29/26, a new extraction appointment was obtained for 02/10/26, with the family member informed, and staff documented that the resident reported no pain at that time, although the family member wanted the tooth extracted as soon as possible. On 02/12/26, the resident returned from the dental office without being seen by a dentist and the appointment had to be rescheduled. On 03/09/26, the dental office again requested written medical clearance for extraction, and staff contacted the resident’s physician and office, with the receptionist stating someone would call back later. On 04/03/26, staff documented that the dental office representative had received the completed and signed medical clearance for review by their doctor and that the oral surgeon only came once weekly, with the office to call back with a date and time. On 04/13/26, staff noted that the medical clearance still had not been reviewed by the dental office MD despite prior assurances, and documented that the resident needed tooth extraction as soon as possible due to pain. Later that day, the dental office confirmed an appointment date and time. The family member reported having requested dental care for several months and expressed frustration with repeated delays and lack of follow‑up by facility staff. The Social Services Director and DON both confirmed that the resident’s dental appointment and tooth extraction had not occurred in a timely manner.
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