complaint·February 10, 2026

LIC9099-C (Page 2) Allegation: Facility did not provide bedding for resident Finding : Unsubstantiated On 01/16/2025, LPA interviewed S1, who stated that R1 was admitted to the facility on 12/22/2024 and left the facility with family on 12/26/2024. S1 stated that R1’s responsible party was informed that linens are shared among residents and that families may bring personal linens if desired. S1 further stated that R1’s responsible party said that they were going to buy their own bed linens. On 12/06/2025 and 01/21/2026 respectively, LPA interviewed W1 and W2, who stated that the family purchased and provided bedding for R1 because the facility did not have bed linens available. However, W2 stated that bedding was brought due to concerns related to R1’s COVID-positive status and the staff did not want to launder R1’s bed sheets. , Although witnesses stated that family provided bedding, there is insufficient evidence to establish that the facility failed to provide bedding as required. Therefore, the allegation is unsubstantiated. Allegation: Facility mismanaged resident’s medication Finding: Unsubstantiated On 01/21/2026, LPA interviewed W2, who stated that the hospice agency responsible for R1 was Anchor Hospice and reported that medications were not present at the facility during the first 24-48 hours. W2 further stated that during a visit, a pill was observed in R1’s mouth, which W2 identified as the last medication administered by caregivers. LIC9099-C Continued... LIC9099-C (Page 3) LPA reviewed an electronically signed letter (dated 12/11/2025) from Medical Director at Anchor Health stating, “R1 was a hospice patient of Anchor Health from the dates of 12/22/2024 thru 12/27/2024. …The patient transferred home on 12/26/2024, and we continued to provide care at home until the patient passed.” LPA attempted to obtain additional records and confirmation from the hospice agency. However, documentation was not received despite multiple attempts. Due to the lack of corroborating documentation and insufficient evidence demonstrating improper medication administration by facility staff, the allegation is unsubstantiated. Allegation: Facility did not meet resident’s nutrition needs Finding: Unsubstantiated On 12/06/2025 and 01/21/2026 respectively, W1 and W2 stated that food and fluids were not offered to R1 and that the family provided broth, soft foods, and Ensure nutritional shakes. S1 stated that R1 was actively transitioning, non-verbal, non-responsive, and on continuous oxygen. S1 further stated that hospice instructed staff not to offer food or fluids unless the resident was oriented and able to swallow due to the risk of choking. LPA reviewed RCFE Care Plan Agreement which noted, “dysphagia pre-caution.” LPA reviewed Anchor Health agency letter that stated, “R1 was ordered a mechanical soft diet by our admission nurse on 12/22/2024. R1 was not taking solid foods and only noted to be taking sips. Our records note that on 12/23/2024 and 12/24/2024 our nurse provided education to facility staff regarding dysphagia and hydration. Education for dysphagia at end of life includes instruction to only feed a patient if they are awake and alert and able to swallow.” LIC9099-C Continued... LIC9099-C (Page 4) Based on the information obtained, LPA did not find sufficient evidence to establish that the facility failed to meet R1’s nutritional needs in violation of applicable regulations. LPA attempted to obtain nutrition documentation and clarification from the hospice agency on 01/27/26 and 02/02/26; however, the requested information was not received. Therefore, the allegation is unsubstantiated. Allegation: Staff did not change resident’s bandages Finding: Unsubstantiated On 12/06/2025, LPA interviewed W1, who stated that wound dressings were not changed by staff and appeared soaked. On 01/21/2026, LPA interviewed W2, who stated that the family performed dressing changes after the second day. On 12/10/2025 and 01/27/2026 S1 stated that the wound was not a pressure injury, was located in the left armpit/breast area, and that wound care was managed by hospice. S1 further stated that staff changed wound dressings in the mornings. LPA reviewed Anchor Health agency letter that stated “Our hospice nurse is responsible for wound care for all our patients. Our instruction to our facilities is to contact hospice when wound is soiled is dislodged.” LPA attempted to obtain wound care documentation and clarification from the hospice agency on 01/27/26 and 02/02/26; however, the requested information was not received. Although information obtained during the investigation suggests that the alleged incidents may have occurred, LPA was unable to establish a preponderance of evidence to determine that the facility violated applicable regulations. Conflicting witness and staff statements, combined with the lack of supporting documentation from the hospice agency responsible for R1’s medical care, prevent a determination that the alleged violations occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED .