Complaint Investigation Report

Per information received from the interviews conducted, Staff #2 checked on Resident #1 around 7:15am on the morning of 10/2/25 and found the resident in bed vomiting and covered in blood. Staff #2 turned the resident on to their side to prevent the resident from choking from the vomit. Staff #2 immediately called the Administrator to advise her about Resident #1. Staff #2 was going to clean Resident #1 but was told by the Administrator not to touch the resident and to immediately call 911. Per the Administrator, she called 911 from her home and explained the situation to the 911 operator. The 911 operator obtained the facility telephone number and conference called Staff #2. Staff #2 was asked about Resident #1's breathing and Staff #2 indicated that the resident's breathing was quiet. Per Staff #2, the resident moaned every time they vomited. Per the Administrator, she lives a short distance away from the home and got in her vehicle and headed to the facility. Per Staff #2, the paramedics arrived around 7:30am and she showed them to Resident #1's room. Per Staff #2 the paramedic checked Resident #1's neck for a pulse and said that resident was dying. They wrapped Resident #1 in the bedsheets and transferred the resident to the gurney that was outside the room. The paramedic again stated that Resident #1 was dying. They asked the staff for the resident's identification to obtain their age and the insurance card. They did not ask for any paperwork or list of medication because they wanted to get Resident #1 to the hospital. Per the Administrator, she got to the corner of the street and saw the paramedics and was able to get the name of the hospital that the resident was being transported to. Per the Administrator, she had a doctor appointment at 8:30am that morning and then went directly to the hospital and got there around 10/10:30am.

Per the investigation regarding the allegation that facility staff did not ensure resident's incontinence care needs were met, the investigation revealed that Resident #1 was restless during the night and staff had checked on Resident #1 around 3am. Per Staff #2, Resident #1 was sleeping soundly and didn't need to be changed. Everything was fine. Per Staff #1 and Staff #2, they check on the residents at night regularly and when they hear the residents making noises. Per Staff #2, on the morning of 10/2/25, they were going to change Resident #1 when they observed that the resident was vomiting and covered in blood and then she was told not to touch the resident due to the urgency to obtain emergency services for the resident. Per Staff #2, the soiled diaper was not dry, it was still wet when she wanted to change the resident. Per