Failure to Timely Arrange Dental Appointment Following Physician Order
Summary
The facility failed to arrange a dental appointment as ordered for a resident who experienced a dental issue. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, schizoaffective disorder, and a history of dental problems, reported to nursing staff that a tooth had fallen out. Although the resident did not initially report pain, the physician was notified and ordered Clindamycin and a dental appointment to be scheduled as soon as possible. Documentation review showed that the dental appointment was not scheduled or completed following the initial order. Subsequently, the resident called 911 for toothache pain and dizziness and was transported to the hospital. Upon return, new orders for antibiotics were given for dental caries and a periapical abscess. It was only after this hospital visit that a dental appointment was scheduled, several weeks after the original physician order. Interviews with facility staff confirmed that the dental appointment was not set up until after the resident's hospital visit, despite the earlier order to do so.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, dementia, malnutrition, and missing teeth had poor oral hygiene, food debris in the mouth, reddened oral tissues, oral pain, and difficulty eating and communicating. Speech therapy changed the diet from mechanical soft to pureed because of oral issues, and Social Work noted no insurance or family support for dental services, showing the facility did not ensure timely dental care for the resident’s needs.
A resident with severe cognitive impairment and multiple comorbidities was left without dentures for an extended period after they were reported missing. Staff were unclear about when the dentures were lost, and the resident did not receive a timely dental referral or intervention as required by facility policy. The delay in dental care and lack of documentation regarding interim measures led to a deficiency in providing appropriate dental services.
Two residents did not receive timely dental care, including follow-up for dentures after tooth removal and assistance with denture replacement after loss. One resident, cognitively intact, was not offered further dental appointments after an initial cancellation, while another with dementia had not been seen by a dentist or assisted with lost dentures, despite care plans requiring such interventions.
A resident with multiple health conditions did not receive timely dental care services, despite having a physician order and requesting a dental appointment for denture repair. Observations showed the resident had no dentures, affecting their ability to enjoy food. Staff interviews confirmed no dental appointments were made since admission.
The facility failed to provide timely dental services for two residents, resulting in unmet dental needs. One resident, with moderate cognitive impairment, had damaged dentures and no follow-up for replacement, affecting their ability to eat. Another resident, cognitively intact, experienced sore gums due to lack of dentures, with no documented dental follow-up. Staff interviews revealed a lack of communication and coordination in addressing these issues.
A resident with a history of cognitive impairments was admitted to an LTC facility with both upper and lower dentures, but later reported missing the lower set. Despite the resident's difficulty chewing and the absence of a documented item inventory list, the facility failed to arrange for dental services to address the issue. Interviews confirmed the lack of documentation or action taken to resolve the missing dentures.
Delayed Dental Care and Poor Oral Hygiene
Penalty
Summary
The facility failed to ensure timely dental care was provided to address Resident #89’s dental needs. Resident #89 was admitted with diagnoses including osteoporosis with pathological fracture, adult failure to thrive, protein-calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse. The resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition. The care plan addressed missing teeth and included daily oral hygiene, notification to the provider with complaints of pain or changes in nutritional status, medications per order, and referral to dental services as needed. Observation and interview on 02/25/26 showed Resident #89 had poor oral hygiene, food debris in the mouth, purplish/reddened oral membranes, and was edentulous. The resident had impaired communication related to poor oral health and reported oral pain, poor intake, and weight loss, and stated the mouth hurt when trying to eat and that he did not like the pureed diet. Speech therapy notes showed the resident had been changed from mechanical soft to pureed food because of oral issues rather than swallowing or aspiration concerns, and the speech therapist referred the resident to Social Work for dental services. Social Work reported the resident had no current insurance to cover dental care and no family or contacts, and the DON later stated the resident was scheduled for a dental exam.
Failure to Provide Timely Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to provide appropriate dental services to a resident who was severely cognitively impaired and dependent on staff for personal care, including oral hygiene. The resident was admitted with multiple diagnoses, including heart disease, dementia, anxiety, and depression, and had upper and lower dentures identified as missing. Despite facility policy requiring referral for dental services within three days of lost dentures, the resident's dentures were not promptly replaced, and there was no evidence of timely dental intervention or documentation regarding measures taken to ensure adequate nutrition and hydration while awaiting dental services. Staff interviews revealed uncertainty about when the dentures were lost and a lack of awareness regarding the resident's current dental status. The Social Service Designee confirmed that the resident should have been seen by a dentist as soon as the dentures were found missing, but the first dental appointment occurred months after the loss. The facility's failure to follow its own policy and ensure timely dental care resulted in the resident being without dentures for an extended period.
Failure to Provide Timely Dental Services and Denture Replacement
Penalty
Summary
The facility failed to provide or offer timely dental services to residents as needed, affecting two of four residents reviewed for dental care. One resident, who was cognitively intact and had all natural teeth removed following a medical procedure, did not receive follow-up for denture impressions or appointments after an initial cancellation due to insurance issues. Despite care plan interventions requiring coordination of dental care and follow-up, there was no evidence that further dental appointments were discussed or scheduled, and the resident confirmed he had not been approached about dentures, which made eating more challenging for him. Another resident, who had dementia and required assistance with self-care, lost her dentures at an unknown time and had not received assistance from the facility in obtaining a replacement. The care plan for this resident included staff observation for oral/dental issues and making dental appointments as needed, but the DON confirmed the resident had not been seen by a dentist for an extended period and was unaware of the missing dentures until the time of the interview.
Failure to Provide Timely Dental Care Services
Penalty
Summary
The facility failed to provide timely dental care services for a resident, identified as Resident #58, who was admitted on 09/01/23 and discharged to the hospital on 08/19/24. The resident had multiple diagnoses, including hemiplegia, cerebral infarction, dysphagia, chronic obstructive pulmonary disease, diabetes, and malnutrition. A physician order dated 09/01/23 indicated that the resident could see dental services as needed. However, there was no documented evidence of any dental appointment being made for the resident since admission. During a care conference on 12/04/24, the resident requested a dental appointment to have dentures repaired, but no action was taken to fulfill this request. Observations on 02/24/25 revealed that the resident had no natural teeth and no dentures in place, which affected their ability to enjoy food. Interviews with the resident and staff confirmed that the resident had not seen a dentist since admission, and there were no dental appointments set up. The Social Services Designee acknowledged the delay in dental services due to appointment complications and confirmed that the necessary paperwork for dental services had been completed, but no services had been provided since the resident's admission.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely routine dental services for two residents, leading to deficiencies in their care. Resident #103, who was admitted with multiple diagnoses including epilepsy and diabetes, had moderate cognitive impairment and no natural teeth. The resident's dentures were damaged in a motor vehicle accident, and despite the need for replacement being noted in a progress note, there was no follow-up documented for obtaining new dentures from December 2024 to February 2025. Interviews revealed that the resident was struggling to eat without dentures, and there was confusion among staff regarding the responsibility for contacting the previous dentist or hospital to address the issue. Resident #60, admitted with conditions such as epilepsy and osteoporosis, was also affected by the facility's failure to provide dental services. The resident, who was cognitively intact, complained of a sore mouth due to the lack of teeth and was placed on a mechanical soft diet when gums became sore. Despite a nursing note indicating the need for a dentist and dietician consultation, there was no documentation of dental follow-up from September 2024 to February 2025. Interviews with staff revealed a lack of follow-up after consent forms were sent to an ancillary company, and there was no clear communication or coordination to ensure the resident received the necessary dental care. The facility's policy on referrals to outside providers requires obtaining physician orders, resident consent, and ensuring progress notes from service providers are integrated into the resident's care plan. However, the facility failed to adhere to these procedures, resulting in a lack of dental care for the residents. The deficiency highlights a breakdown in communication and coordination among staff, leading to unmet dental needs for the residents involved.
Failure to Provide Prompt Dental Care for Missing Dentures
Penalty
Summary
The facility failed to provide prompt and appropriate dental services for a resident who was missing their lower dentures. The resident, who had a history of schizoaffective bipolar disorder, depression, and dementia, among other conditions, was admitted to the facility with both upper and lower dentures. However, there was no item inventory list upon admission to confirm the presence of the dentures. The resident reported occasional difficulty chewing due to the absence of the bottom dentures, as noted in dietary progress notes. Despite this, the facility did not arrange for dental services to address the missing dentures. Interviews and observations revealed that the resident was only wearing top dentures and could not recall when the bottom dentures went missing. The facility's Regional Director of Clinical Services confirmed that there was no documentation regarding the missing dentures or any arrangements for dental services after the issue was reported. This deficiency affected one of the six residents reviewed for personal property, highlighting a lapse in the facility's responsibility to ensure residents receive necessary dental care.
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.
