complaint·January 6, 2022

However, based on interview with S1, S1 stated resident has a history of refusing to be clothed in pajama pants. S1 added the pendant is tied around the rails because R1 did not want it around R1's neck. However, it was within R1s reach. Based on record review, on 3/26/2020, the day of the incident, R1 vomited, and was cleaned and changed by a caregiver on shift. S2 does not recall caregiver's name. When S2 was informed of R1's condition, S2 observed R1 gasping for air and immediately called 9-1-1. Allegation: Facility failed to notify responsible party Based on information obtained by complainant, complainant received a call from local law enforcement and was not contacted by facility. However, LPA obtained a copy of the incident report noting that facility had contacted R1's responsible party. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.