Complaint Investigation Report

During visit on 03/07/2025, LPA Marrufo interviewed staff S1 and S2. Both S1 and S2 stated to have provided care to R1. Both S1 and S2 stated to have observed R1 begin to lose teeth. S1 stated that S1 provided care for R1 including bathing, toileting, and brushing R1’s teeth. S1 stated S1 would apply toothpaste to R1’s toothbrush and brush R1’s teeth up and down and side to side and would also brush R1’s molars. S1 stated S1 would have R1 spit out the toothpaste and rinse with mouthwash and spit out the mouthwash. S1 stated the bottle of mouthwash was stored in a locked cabinet in R1’s room and S1 would unlock the mouthwash with a key. S1 stated S1 would floss R1’s teeth. S1 stated to have worked from 6:00 AM to 2:00 PM each day. S1 stated to have assisted R1 with brushing R1’s teeth and maintaining R1’s dental hygiene each morning and afternoon. S1 stated that when S1 arrived at 6:00 AM, S1 would observe that R1’s teeth were clean. S1 stated to have never arrived at the beginning of a shift and observed any signs that R1’s teeth had not been cleaned by the staff of the prior shift. S1 stated to have never observed food in R1’s mouth or on R1’s teeth at the beginning of S1’s shift when S1 would brush R1’s teeth.

S1 stated that S1 would change R1’s diapers any time R1’s diapers became soiled. S1 stated to have changed R1’s diapers as needed, which was usually once every hour. S1 stated to have changed R1’s diaper and cleaned R1’s private areas with wipes.

S2 stated to have assisted R1 with brushing R1’s teeth and with changing R1’s diapers. S2 stated that R1 would close R1’s mouth while S2 was brushing R1’s teeth, making it difficult for S2 to brush all R1’s teeth. S2 stated R1 would not let S2 use floss to clean R1’s teeth. S2 stated to not remember if S2 used mouth wash with R1. S2 stated to have never noticed anything that would make S2 think that the staff on the prior shift did not brush R1’s teeth.

S2 stated to have changed R1’s diapers once every two hours. S2 stated to have used wipes and cream to clean R1’s private area while changing R1 into new diapers. S2 stated to have never observed any indication that the staff from the prior shift had not changed R1’s diapers.

Both S1 and S2 stated to have never observed R1 to have a shortage of diapers.