Complaint Investigation Report

Allegation: Facility did not provide bedding for resident

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

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.