Inspection·June 18, 2024

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 clinical record review and staff interview it was determined that the facility failed to obtain dental care for one of six residents reviewed for dental concerns (Resident 1). Residents Affected - Few Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE]. A review of the diagnoses list for Resident 1 included the following: severe intellectual disabilities, a mixed receptive-expressive language disorder, and the need for assistance with personal care. Review of the current physician orders for Resident 1 included the following: Dental as needed and nothing by mouth, both dated February 26, 2024. Review of the current Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 1 dated April 6, 2024, revealed that the resident is rarely/never understood and is dependent on staff for personal hygiene. An admission MDS for Resident 1 dated March 4, 2024, revealed that the staff assessed the resident has having obvious or likely cavity or broken natural teeth. Nursing documentation for Resident 1 dated March 4, 2024, at 9:15 AM revealed the resident has her own teeth with some missing and some cavity like areas. Nursing documentation for Resident 1 dated June 4, 2024, at 6:42 AM revealed the resident has natural teeth with some missing and some cavity like areas. Observation of Resident 1 on June 18, 2024, at 11:30 AM with the Director of Nursing (DON) revealed that the resident had natural teeth. There were some teeth missing. The gums appeared erythematous (reddened) in a thin line just above the front teeth on at least two of the teeth in the upper jaw. The teeth were discolored. The exam was limited based on resident movement. Further clinical record review for Resident 1 revealed no evidence that the facility offered the resident's responsible party routine dental services since admission or addressed the concerns related to the nursing documentation and MDS that assessed the resident's teeth as some missing and some cavity like areas. (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: 395350 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 395350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Locust Grove Retirement Village 69 Cottage Road Mifflin, PA 17058 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)