Complaint Investigation Report

On March 6, 2025, LPA Manuel Monter interviewed Staff S1-S3. Staff S1-S3 stated residents are checked/changed every 2 hours. S1 and S2 stated staff brush residents’ teeth every day; morning, after lunch and after dinner. S3 stated R1 will sometimes not want to have his/her teeth brush and is combative and will refuse. S3 stated staff tries to brush R1's teeth but can't force him/her.

S1 stated staff does put two diapers for residents to prevent the resident from being soaked at night. (LPA reiterated what staff S1 stated, then S1 recanted and stated staff doesn’t put residents in double diapers.) S1 stated the staff puts residents diaper then they put the pads in the residents bed to make sure the resident doesn’t soak. Staff S2 stated staff only puts one diaper on the residents. S2 stated the facility does put pads for R1. S3 stated he/she puts a double diaper on the resident during the evening, when residents are going to sleep. S3 stated he/she does this so the residents wont soak the bed at night.

LPA Monter interviewed residents R1-R4. Residents R1-R3 did not respond to LPA’s questions. 3 Out of 4 residents interviewed (R1-R3) ignored LPA and did not provide responses to LPA’s questions, while being distracted by television, radio and or ignored LPA. Resident R4 stated he/she declined to be interviewed and stated he/she preferred to go to sleep.

On April 14, 2025, LPA Monter interviewed R1's Service Coordinator (SC). SC stated he/she doesn’t know if R1 wears double diapers. SC stated he/she has no knowledge of residents wearing double diapers.

SC stated its hard to brush R1's teeth. SC stated R1 goes to the dentist once year. SC stated R1 needs sedation when he goes to his dentist appointments. SC stated R1 resists and doesn’t like it and bites whenever staff tries to brush his/her teeth. SC stated they might add this behavior to R1’s Individual Program Plan. SC stated A foreign object entering a residents mouth, its hard if the resident refuses or isn’t cooperating.