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. (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: 675968 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 675968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stone Oak Care Center 505 Madison Oak Dr San Antonio, TX 78258 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)