F 0791
Provide or obtain dental services for each resident.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure that residents obtain needed dental services,
including routine dental services and to ensure the resident was provides the assistance needed or
requested to obtain these service for one of two residents (Residents #1) reviewed for dental services.
Residents Affected - Few
The facility failed to assist in providing routine dental services for Resident #1. Resident #1 was assessed
on 11/07/2022 and observed to have dental issues however did not recieve routine treatment which caused
Resident #1 to have a tooth abscess with pain.
This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.
Findings include:
Record review of Resident #1's electronic face sheet face printed 03/19/2024 revealed a [AGE] year-oldmale admitted to the facility 09/30/2022 and re admitted on [DATE] with diagnoses that included chronic
congestive heart failure (long-term condition that happens when your heart can't pump blood well enough
to give your body a normal supply), and kidney failure (one or both kidneys no longer work)
Review of the quarterly MDS assessment dated [DATE] revealed section L oral/ dental status was not
completed.
Review of Resident #1's care plan with a problem start date of 11/07/2022 revealed Resident #1 had oral/
dental health problems regarding poor oral hygiene, missing broken teeth, Carious dentition (prevalent
chronic infectious disease resulting from tooth-adherent cariogenic bacteria that metabolize sugars to
produce acid, which over time demineralizes tooth structure)
Review of Resident #1's progress nurse authored by DON 02/23/2024 revealed Resident #1 was seen by
the Nurse Practitioner due to his left lower jaw being swollen. Resident #1 was prescribed Augmentin 500
milligram tablets every 12 hours for 7 days due to tooth abscess.
Review of the dental referral book revealed no referral for Resident #1 to see the dentist had been
completed.
Interview on 03/19/2024 at 12:00 PM with Resident #1 revealed he had been in the facility for 3 years.
Resident #1 stated he had not been to the dentist since being in the facility and needed to go. Resident #1
stated he had an abscess and was experiencing pain in his mouth but did not describe the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676215
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676215
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Dallas
4200 Live Oak St
Dallas, TX 75204
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0791
pain. Resident #1 stated he was able to eat. Observation of Resident #1 having several missing teeth.
Level of Harm - Actual harm
Interview on 03/19/2024 at 1:30 PM with the Social Worker revealed she had worked in the facility since
February 2024. She stated she was responsible for making the referrals for dental services. She stated
typically residents would let her know if a referral was needed. The Social Worker stated she had not made
a referral for Resident #1 and was not aware that he needed to be seen by a dentist. The Social Worker
stated if the resident had an abscess, then they should have been seen by a dentist.
Residents Affected - Few
Interview on 03/19/2024 at 3:30PM with the Director of nursing and Administrator revealed if a resident
clinically needed to see a specialist, then the resident or any staff could let the Social Worker know and the
Social Worker would make the referral. The Director and Administrator stated regarding Resident #1 he was
seen by the nurse practitioner for the abscess and was treated for the infection and they were not aware of
the resident needed to see the dentist. The Director of Nursing and Administrator stated they both spoke
with Resident #1 frequently and he had not voiced any concerns of oral pain.
A policy regarding referrals and dental services was requested after exit however the Administrator stated
the facility did not have those polices.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676215
If continuation sheet
Page 2 of 2
