complaint·April 17, 2026

Continued from 9099... resident was sent to the hospital for being “warm to touch.” Complainant expressed concern that R1 is non-verbal with dementia, is unable to verbalize pain and was sent to the emergency room alone. Per file review, a record of R1’s temperature was not documented. Review of the After Visit Summary indicated that resident was diagnosed with a Urinary Tract Infection and Dental Caries with after care instructions indicating that they were to follow up with their medical doctor in “1 day (around 12/24/2025)” and were to “see a dentist as soon as possible for evaluation for tooth extraction.” Facility was unable to provide documentation showing that there was a follow-up with their doctor within one day, as instructed in that after visit summary, or that an appointment was sought by the facility for a follow-up with a dentist. A follow up visit was conducted on 1/6/2026 with R1’s Nurse Practitioner. Per Nurse Practitioner’s order R1 has “gingivitis (gum inflammation) and also periodontitis - inflammation around the root of the molar, which is "cracked” and defined that treatment will be an extraction or root canal under anesthesia. The doctor’s order went on to say that as an intermediate step, have the visiting dental hygienist conduct a thorough cleaning of R1’s teeth and gumline. Order instructed facility that if R1 still has tenderness, inflammation, poor appetite, mouth pain, or behavior changes 1-2 weeks after the cleaning, R1 will likely require further evaluation and treatment with extraction or root canal. Finally, the facility was instructed to “provide mouth hygiene on a daily basis; use Orajel on toothbrush first to numb the gum line, then use Sensodyne toothpaste paying special attention to the upper right molars.” Interviews with five (5) staff indicated they assist R1 with teeth brushing but three of five were unaware of any special instructions with the remaining two not having a response to the question. Individual staff noted that R1 bites their toothbrush when staff are trying to brush their teeth and swallows the water with two staff indicating it is difficult for the resident to open their mouth. Based on review of R1’s file, the care plan was not updated following the emergency room visit or the nurse practitioner’s order to reflect changes in R1’s care needs. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D .