complaint·October 8, 2025

Page 2. 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 continued on LIC9099-C Page 3. interviews conducted with Resident #3 and Resident #5, the staff change the residents timely. Per Resident #5, they are able to use the bathroom themselves but use a pull up for accidents. Per information obtained from the interviews conducted, there is insufficient evidence to support the allegation that facility staff did not ensure resident's incontinence care needs were met . Although the allegation may have happened or is valid, there is insufficient evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Per interviews conducted with the Administrator regarding the allegation that facility staff did not communicate resident's health history/health condition to medical personnel, information revealed that the facility does provide emergency personnel with resident's identification, insurance card, a list of medication and medical information. Per Staff #2, on 10/2/25 the paramedics only asked for the residents identification to determine the resident's age and the insurance card and due to the resident vomiting blood, rushed Resident #1 to the hospital. They did not ask for any thing else or ask any questions. Per interview with the Administrator, when she was done with her doctor appointment on 10/2/25, she went to the hospital. When she got there, Resident #1 was still in the emergency room. Bleeding had stopped, resident was cleaned up and had an MRI. The MRI results were pending. Per the Administrator, she had provided the nurse with information regarding the resident's spinal issues and a copy of the residents medications that she had picked up from the facility and the nurse indicated that they didn't need it because the resident was on IV. Per the Administrator, she left a medication list with the ICU nurse and the Pharmacist wrote down the Resident's medications. Per information obtained from the interviews conducted, there is insufficient evidence to support the allegation that facility staff did not ensure resident's incontinence care needs were met. Although the allegation may have happened or is valid, there is insufficient evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated at this time. Exit interview was conducted.