Health inspection·April 9, 2025

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to track, find, replace, and follow up with two of two Residents (Resident 2 and Resident 3) whose dentures were lost at the facility. Residents Affected - Few This failure resulted in two Residents not having their teeth to eat and talk which impacted their dignity and psychosocial well-being. Findings: During a review of Resident 2 ' s admission record titled Face Sheet, undated, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] for Heart Failure (A chronic condition where the heart doesn ' t pump blood as well as it should.). During a review of Resident 2 ' s Minimum Data Set (MDS- an assessment tool to guide care), the MDS assessment indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a mental status exam) score of 15 indicating intact cognition. The MDS assessment also indicated Resident 2 required set up and assistance with oral hygiene, to include managing, denture soaking, and rinsing with use of equipment. During a record review of the Resident 2's Care Plan Essentials, dated 12/21/23, the care plan indicated Resident 2 had upper dentures on admission to facility. During an interview on 4/9/25 at 12:10 p.m. with Resident 2, Resident 2 stated her upper dentures were lost about 2 months ago. Resident 2 stated, the facility would get upset with her whenever she would ask about them. Resident 2 stated she was having to eat soft foods because of not having teeth to chew meat. Resident 2 stated she mostly ate mashed potatoes and soup. Resident 2 stated her dental insurance would cover the denture replacement, but no one at the facility had gotten back to them regarding her lost dentures. Resident 2 stated that it was upsetting not having her dentures. Resident 2 stated she felt like the facility blamed her for her missing dentures. Resident 2 also stated staff told her they found another Resident's dentures in the laundry room but they were not hers. During an interview on 4/9/25 at 1:40 p.m. with Director of Social Services (DSS), DSS stated they were aware of Resident 2 ' s lost dentures. DSS stated they found lost dentures in the laundry room, but they did not belong to Resident 2. During a review of Resident 3 ' s admission record titled, Face Sheet, undated, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of Cerebral Infarction, (A condition where the brain tissue dies due to lack of blood flow and oxygen), and is on hemodialysis, Page 1 of 2 056389 056389 04/09/2025 Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (A medical procedure that uses a machine to filter waste products and excess fluids from the blood, when the kidneys are failing) for end stage renal (kidney) disease. During a review of Resident 3 ' s MDS assessment, the MDS assessment indicated, Resident 3 had a BIMS score of 13. The MDS assessment also indicated Resident 3 required set up and assistance with oral hygiene, to include managing denture soaking and rinsing with use of equipment. During a review of the facility's document titled, Observation Data List Report, the Observation Data List Report indicated Resident 3 had both upper and lower dentures upon admission to the facility. During a review of Resident 3 ' s Progress Note, dated 9/12/24, at 12:18 p.m., the Progress Note indicated a call had been placed to Lumina Dental and that the facility would pay for x-rays and dentures. During an interview on 4/9/25 at 11:17 a.m. with Resident 3 ' s Family Member (FM), FM stated he contacted the facility about his dad ' s lost dentures, but no one had gotten back to him. During an interview on 4/9/25 at 11:30 a.m. with Social Worker (SW1), SW1 stated they were not aware of Resident 3 ' s lost dentures. SW1 stated the facility did not have a tracking log for Residents who had lost their dentures. SW1 stated they were not sure if Resident 3 ' s lost dentures were discussed at the Interdisciplinary Team (IDT-team members from different departments who work together to resolve patient care problems) meetings. During an interview on 4/9/25 at 12:50 p.m. with Resident 3, Resident 3 stated no one had gotten back to him about his lost dentures. Resident 3 stated he was using old temporary partials that did not fit properly which caused him to have trouble speaking and eating. Resident 3 stated his social interactions had been impacted. Resident 3 stated he felt upset and bad about himself. Resident 3 also stated his son has been trying to help with his lost dentures, but the facility had not gotten back to his son either. During an interview on 4/9/25 at 1:40 p.m. with Nursing Supervisor (NS), NS stated Resident 3 had a dental appointment scheduled by SW1. NS stated SW1 was responsible for following up on lost dentures. During a review of the facility's Policy and Procedures (P&P) titled, Residents and Personal Property, the P&P indicated, .reports of misappropriation or mistreatment of resident property are to be investigated through the resident theft/loss/grievance process and documented in the progress notes or through the grievance process . 056389 Page 2 of 2