Health inspection·September 22, 2023

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 assist residents in obtaining routine dental services to meet the needs of 1 of 11 residents (Resident #27) reviewed for dental services, in that: Residents Affected - Few The facility did not assist Resident #27 with obtaining dental services when her bottom dentures were reported missing. This failure could place residents at risk of not having their oral health care needs met. The findings included: Record review of Resident #27's electronic medical record revealed she was a 84 year -old female admitted to facility on 3/9/2023 with diagnoses which included: senile degeneration of brain (a decrease in the ability to think, concentrate, or remember.), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) abnormal weight loss, muscle wasting and atrophy( the wasting (thinning) or loss of muscle tissue.) and unspecified dementia with other behavioral disturbance (A person can have unspecified dementia(loss of memory) with or without behavioral disturbances. When behavioral disturbances are present in unspecified dementia, they tend to be milder and less aggressive. They can include impaired concentration, apathy, anxiety, and agitation.). Record review of Resident #27's nursing admission assessment, dated 3/9/2023 authored by LVN A, revealed Resident #27 had a set of upper and lower dentures upon admission documented in section A; 6) Valuable belongings brought in by admission, lower dental appliance, upper dental appliance. Record review of Resident #27's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 0, which indicated cognitive impairment. Further review revealed Section L did not indicate the resident had upper or lower dentures. Record review of Resident #27's careplan with a initiated date of 3/10/2023, revealed, at risk for oral care issues due to dementia. Interventions: Provide oral care as indicated. Further review revealed there was no mention of the resident's dentures. During an interview with Resident #27 on 9/20/2023 at 10:30 a.m., the resident stated, I have teeth in mouth, see the top ones and I don't know where the rest of them are. During an observation on 9/21/2023 at 10:30 a.m. revealed Resident #27 had only the top set of her dentures in her mouth. Page 1 of 2 675968 675968 09/22/2023 Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with LVN B on 9/20/2023 at 10:45 a.m., LVN B stated she had only seen the top dentures in Resident #27's mouth and could not remember ever seeing bottom dentures. LVN B further stated it was important for residents who resided in the memory care unit to have staff check the residents oral status to make sure they do not need a dental assessment. LVN B stated dementia could cause residents to not want to eat and they could lose weight , and if their teeth or lack of teeth were not taken care of then they could lose weight. During an interview with the ADON on 9/20/2023 at 11:00 a.m., the ADON stated she was only aware of Resident #27 having the top dentures since she had been here. The ADON further stated it was important for residents with dementia to have healthy mouths for eating. During an interview with LVN A on 9/22/2023 at 9:30 a.m., LVN A stated she admitted Resident #27 on 3/9/2023 and she remembered the resident having top dentures and bottom dentures. LVN A confirmed she was the author of Resident #27's admission assessment and the resident had a set of upper and lower dentures upon admission documented in section A; 6) Valuable belongings brought in by admission, lower dental appliance, upper dental appliance. During an interview with the Administrator on 09/22/2023 at 11:25 a.m., the Adminstrator stated she was not aware of Resident #27 missing her dentures and for how long, until Resident #27's family member mentioned it during a care plan meeting on 9/14/2023. The Administrator stated it was important for residents to have oral status assessed and if they needed a dental consult then the facility should arrange one. Record review of the facility's policy titled, Abuse Guidance: Preventing, Identifying and Reporting, dated 2/2017, revised 10/2022, revealed, Compliance Guidelines: Every resident has the right to be free of abuse, neglect, and misappropriation of property, and exploitation. 675968 Page 2 of 2