Health inspection·April 4, 2023

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 interview and record review the facility failed to follow-up with the dental services for one (Resident 1) of three residents when Resident 1's tooth was avulsed. Residents Affected - Few This failure resulted in Resident 1's tooth not reimplanted for 11 months or not having the replacement tooth for 11 months. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including anoxic brain injury, persistent vegetative state and dependence on respirator. Review of Registered Nurse's (RN A) notes, dated 3/31/22, indicated resident 1 banged his tooth to side rail during activity of daily living (ADLs) while being turned. Review of the facility dentist (DT) notes, dated 4/3/22, indicated Resident 1 sustained avulsion injury of a permanent tooth after hitting his tooth on the bed side rail. Further review of the DT notes indicated Resident 1's responsible party (RP; person who makes all care decisions for the resident) was to pursue a dental implant to restore the empty space in the mouth where a tooth was. Review of Licensed Vocational Nurse's (LVN B) notes, dated 4/16/22, indicated Resident 1 was approved for dental referral for consultation. Review of the inter-disciplinary team care conference, dated 4/25/22, did not indicate how the tooth reimplantation will pursue. During an interview with the facility dentist (DT), on 1/30/23 at 3:00 p.m., the DT indicated for an implant Resident 1 would need hospitalization and anesthesia (use of medications to prevent pain during surgery). Review of Resident 1's clinical record did not indicate Resident 1 was hospitalized for the reimplantation. During an interview with the Social Services Director (SSD), on 1/30/2023 at 2:15 p.m., the SSD confirmed the RP wanted Resident 1 to have an implant. She stated the Administrator was hesitant to pay for services and to only find a place that took the RP's insurance. The SSD stated the burden fell (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: 555204 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 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 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)