Staff revealed that they would assist residents with brushing their teeth at least two times a day – before breakfast, and before the residents go to bed. Staff claimed that R1 allowed staff to brush their teeth. The Administrator claimed they took R1 for a dental exam on 10/21/2019. The physician’s note regarding R1’s appointment from 10/21/2019 documented that R1 had broken teeth with decay, yet no active infection. It was documented that R1 was not cooperative, and it was not possible to complete a comprehensive exam due to R1’s dementia. The dentist recommended teeth cleaning, extraction, and future treatment in case of pain or infection. However, R1 was not documented with any pain or infection at the time of the visit. The Administrator was present during the visit and understood that R1 needed a procedure that would require R1 to be put to sleep. However, the dentist communicated that due to R1’s age, R1’s doctor possibly would not clear R1 to be put to sleep. As a result, the Administrator asked the dentist to discuss the treatment plan with R1’s conservator. At the time of the interview, R1 did not have surgery to have their teeth removed.

Interviews with R1’s case manager that oversees R1’s care indicated that they were notified of R1’s dental visit on 10/21/2019 and was aware that R1 was non-compliant during the visit. R1 allegedly was unable to ‘sit still’ during the dentist visit. Per the interview conducted with R1’s case manager for R1’s conservatorship, they did not feel that R1 needed to see the dentist since the last visit on 10/21/2019. It was further communicated that staff were communicative regarding any updates pertaining to R1’s care and did not observe any staff negligence as it related to the care R1 received.

Based on the information obtained in records review and interview, there is insufficient evidence to support the claim that facility staff failed to address R1’s dental needs. Any dental procedures had to be approved by R1’s conservator. It was noted by both the staff and the attending dentist that R1 was combative during the visit. However, R1 was not in pain nor did R1 have an infection at that time. In addition, staff indicated that they assisted residents with brushing their teeth, and residents interviewed claimed that staff assisted with hygiene and dental needs. The allegation is deemed unsubstantiated at this time.

Regarding the allegation: Resident sustained an unwitnessed fall resulting in injury.

It was alleged that due to staff negligence, R1 sustained an unwitnessed fall that resulted in injury. Staff stated that all residents, including R1, were checked every two hours. Facility notes documented that R1 was found on the floor next to their bed on 06/10/2021 at approximately 10:15 a.m. R1 was transferred to the emergency room, and notes indicated that R1’s conservator was notified. Notes indicated that R1’s family member was also notified, as they had called at the time R1 was being sent to the emergency room. R1 returned to the facility on 06/10/2021 at approximately 3:00 p.m. with stitches to the forehead. A follow up appointment was requested, which was communicated both to R1’s conservator and R1's family member.

Interviews with R1’s case manager that oversees R1’s care indicated that they were notified of R1’s fall from 6/10/2021. It was further communicated that staff were communicative regarding any updates pertaining to R1 and did not observe any staff negligence as it related to the care R1 received. R1’s case manager for R1’s conservatorship indicated that because of the fall, the facility responded immediately and sent R1 out to the hospital. A review of resident records indicated that R1 ambulated with a walker, but there was no indication that R1 suffered frequent falls at the facility.

According to staff interviews, the facility attempts to minimize fall risk by providing two (2) hour checks and stand-by assists. Staff provided a room checklist for 6/10/2021, in which it was documented that R1 was checked on at 8:00 a.m., and 10:00 a.m., on 06/10/2021. As such, even if staff were to check on residents as discussed within two (2) hours checks, it does not prevent a resident from suffering a fall within that time frame. Staff also followed protocol and ensured that R1’s responsible party (conservator) was notified of the incident. Therefore, there is insufficient evidence to prove that the resident fell and suffered an injury due to staff negligence. Thus, the allegation is deemed unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.