Health inspection·February 28, 2025

F 0791 Provide or obtain dental services 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, interviews, and record reviews, the facility failed to assist residents in obtaining routine and 24hour emergency dental care to meet the needs of 1 of 3 residents (Resident #1) reviewed for dental services in that: Residents Affected - Few The facility did not assist Resident #1 with obtaining dental services when her top dentures were reported missing on 9/29/24 . This failure could place residents at risk of not having their oral health care needs met. The findings included: Record review of Resident #1's electronic medical record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Cerebral infarction (is a medical condition where blood flow to the brain is interrupted), kidney disease (is a condition where the kidneys are damaged and cannot function properly), and Dementia (condition that cause a progressive decline in cognitive function, memory, and behavior). Record review of Resident #1's inventory sheet, 9/10/24 , revealed Resident #1 had a top denture upon admission. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, which indicated intact cognition. Further review revealed Section L did not indicate the resident had upper or lower dentures. Record review of Resident #1's care plan, dated 9/25/2024, revealed, [Name of resident] is at risk for oral health problems related to no natural teeth. Interventions: Coordinate arrangements for dental care. Further review revealed the resident's dentures were not mentioned. Record review of Resident #1's physician monthly orders from February 2025 revealed a diet order for a regular diet. Record review of Resident #1's weight record from 9/9/24 to 2/19/25 revealed resident #1 gained 3 lbs. Record review of an email conversation between the previous Texas area president and a family representative for Resident #1, dated 9/27/24, revealed, It appears she is missing top dentures. Page 1 of 2 455817 455817 02/28/2025 San Antonio North Nursing and Rehabilitation 501 Ogden San Antonio, TX 78212

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 2/28/25 at 10:10 a.m., revealed she was unaware Resident #1 was missing her top dentures, and by Resident #1 continuing to eat without her top dentures could risk possible choking. During an interview with the Texas area president on 2/28/25 at 12:55 p.m. revealed she recalled email conversations between Resident #1 family representative but could not recall the contents of the email conversation. During an interview with Resident #1 on 2/28/2025 at 11:41 a.m., Resident #1's revealed, The current nursing home lost my top false teeth. I'm worried that I could choke while eating. During an interview with Resident #1's representative on 2/28/25 at 12:30 p.m., revealed she notified the Texas area president (previous administrator) on 9/27/24 top dentures for Resident #1 were missing. Observation on 2/28/2025 at 11:42 a.m. revealed Resident #1 had no natural teeth on the top of her mouth. During an interview with CNA A on 2/28/25, at 11:55 a.m., CNA A stated Resident #1 had upper dentures at the time of her admission in September 2024 but could not remember when they went missing. CNA A expressed concern Resident #1 was at risk of choking if she continued to eat without her upper dentures. During an interview with the Administrator on 2/28/25, at 12:00 p.m., the Administrator indicated he was unaware Resident #1 was missing her upper dentures. The Administrator further noted Resident #1 could potentially choke if she continued to eat without her upper dentures. The Administrator highlighted the importance of assessing residents' oral health, stating that if a dental consultation was necessary, the facility should arrange for one. Record review of the facility's policy titled Dental Services revised 2018, revealed, Dentures will be protected from loss or damage to the extent practicable, while being stored. 455817 Page 2 of 2