Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility failed to assist resident with oral hygiene

The detail of the complaint alleges that R1 doesn’t consistently practice oral hygiene, and staff are not assisting her.

On 10/9/25 at 10:36am, the Department interviewed the Executive Director (A1) who stated that she was not working at the facility in 2022, however A1 informed the Department that any orders from medical professionals are followed. A1 further stated, “if residents receive a signed order for dental hygiene assistance, the order would be put on the care plan, and it would be followed by our care partners.” A care partner is assigned to the resident who needs assistance and the order is carried out as required.

On 10/9/25, between 10:30 and 12:30pm, the Department interviewed 3 staff (S1-S3) regarding the allegation, and of those interviewed 2 out of 3 were working at the facility in 2022 during the time of the allegation. 2 out of 3 stated that R1 was given help with her oral hygiene when they were allowed to do so; they further explained that at times resistance came from R1’s husband who limited any contact from caregivers to assist R1, so they did what they could.

On 10/9/25, between 1:30 and 3:30pm, the Department interviewed 3 residents (R2-R4). R1 could not be interviewed as she passed away on 2024. Of those interviewed 3 out of 3 stated that they don’t have dental issues but if they needed help, the staff would help them. 3 out of 3 stated that they make their own dental appointments.

On 10/9/25, the Department obtained, reviewed, and evaluated the following documents: R1 Physicians report (dated: 4/11/24), R1 pre-placement appraisal (date: 9/20/21), R1’s Personal Services Plan (dated: 8/25/22, 2/25/22), Progress notes (dated: 10/2022), Prescription from dentist (dated: 10/25/22. There were no other dental information available for review.