Health inspection·August 22, 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 timely follow up on the dental treatment recommended for one of two residents (Resident 1). On 9/17/2024, the dentist had recommended oral surgery for Resident 1. This failure had resulted in fluctuates of Resident 1's mood and potentially affecting his overall quality of life. The referral for the oral surgery was only sent again by the facility on 6/25/2025, which was a delay of 281 days, equivalent to 9 months and 8 days. During an observation and concurrent interview on 8/19/25 at 12:30 p.m. with Resident 1, a [AGE] year-old male with a history of dementia (progressive or persistent loss of intellectual functioning and memory), atrial fibrillation (abnormal heart rhythm), and poor dentition, was observed with upper front teeth (numbers 7-10) visibly missing or decayed, eating mashed potatoes. Resident 1 stated, he lost his front teeth years ago and stopped using his partial lower dentures due to pain. Resident 1 stated, the dentist had told him he needed oral surgery, but no follow-up occurred.During an interview on 8/19/25 at 12:45 p.m. with the Registered Dietitian (RD), RD stated, the facility had placed Resident 1 on a long-term soft diet due to dental issues. The RD stated, Resident 1 had requested dentures multiple times.During an interview on 8/19/25 at 2:55 p.m. with the Director of Nursing (DON), DON explained, Resident 1 experienced delays in care coordination because Resident 1 needed to have medical clearance before oral surgery, due to multiple comorbidities.During a telephone interview on 8/20/25 at 11:30 a.m. with Resident 1's Durable Power of Attorney (DPOA), DPOA stated, Resident 1 had been waiting nearly a year for extractions and dentures since the dentist referred Resident 1 for oral surgery in September 2024. Despite multiple follow-ups with the dentist and social worker, the DPOA observed Resident 1 had little to no progress with dental care.During a telephone interview on 8/20/25 at 3:42 p.m. with the dentist (DDS), DDS stated, Resident 1 had been evaluated emergently in September 2024, and referred Resident 1 for oral surgery and created a denture plan. DDS stated, a misunderstanding with the DPOA caused the delays in dental care and required the DDS to reinitiate the referral in June 2025.During an interview on 8/21/25 at 9:30 a.m. with a social worker (SW), SW stated, Resident 1's DPOA had been coordinating Resident 1's dental care and there was confusion regarding where Resident 1 was supposed to go for oral surgery. SW stated, Resident 1 had expressed he was feeling situational depression due to lack of dentures and the inability to eat solid food.Review of emergency dental note dated 9/17/2024 at 4:48 p.m. indicated, Resident 1 was evaluated as an emergency and was complaining of pain in the upper jaw with increasing severity over the previous few days and weeks. Grossly decayed anterior (front) teeth numbers 7,8,9,10. Dietary staff are informed of change in diet will be needed until lower appliance is made. Referral made to specialty clinic for multiple extractions. Treatment plan for full upper dentures (FUD) and partial lower dentures (PLD).Review of dental note dated 9/25/2024 3:41 p.m. indicated, Intra oral (in the mouth) and extra oral (outside the mouth) exams performed. Treatment plan was completed and presented to Resident 1 and DPOA. Prescription given: Resident 1 referred to outside Residents Affected - Few Page 1 of 2 555917 555917 08/22/2025 Veterans Home of California - West Los Angeles 11500 Nimitz Avenue Los Angeles, CA 90049

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oral surgeon for extraction of teeth, 2,3,6,7,8,9,10,11,14,15. Diet texture modifications needed: Dietary staff is aware of his dental condition and will be informed when change in diet will be needed when extractions are done and new appliance (dentures) are made.Review of social service note dated, 11/12/24 at 10:03 a.m. indicated, Social Work Quarterly Assessment: Resident 1's DPOA reported that Resident 1 had ongoing situational depression, and it primarily surrounded the difficulty and struggles of being wheelchair bound and being on a modified diet. Resident 1 stated, Yeah, if I could eat anything I want and walk my life would be a lot better. DPOA stated, We are currently working with the facility to get Resident 1 assigned to a dentist that has special equipment to care for him.There was no documentation Resident 1 received any further evaluation or follow-up regarding dental care between 11/12/24 and 5/12/25.Review of social service note dated 5/12/25 at 1:21 p.m. indicated, Resident 1's DPOA reported Resident 1's mood varied from day to day. DPOA stated, most of it had to do with Resident 1's situation with the dentist and needing teeth removed. The plan was to have Resident 1 go to an outside oral surgeon to get them removed and nothing had been done. Resident 1 stated to SW, Yes, If I can get my new dentures, my quality of life would be better, eating mushed up food is not as filling or satisfying.Review of Dental Note dated, 6/25/25 09:57 p.m. indicated, Prescription (for oral surgery) given referral to be sent again with diet texture modifications needed: Dietary staff will be informed if change in diet will be needed. Resident 1 has no dentures. Resident 1 had an appointment with oral surgery provider, for extractions and denture impressions.Review of Facility Policy titled, Dental Services for Residents dated, 7/17/25 indicated, .3. Emergency Dental Care: b. The Home will provide or make arrangement for the transportation of the Resident. c. Those Residents who have lost or damaged dentures will be promptly referred to a dentist within three days. During an interview on 9/1/25 at 11:00 a.m., with the Standards and Quality Manager (SCM), SCM stated, the above policy was reviewed with no revisions made on 7/17/25. SCM stated, the previous policy and procedure would have been the same. 555917 Page 2 of 2