RICHMOND, Va. -- David Jones always insisted on sitting at the head of his family's dinner table.
"This was always his chair to sit in," Jones' daughter, Tracey Pompey, said while showing his chair.
Jones didn't like the chair because he wanted to be in charge, but, instead, because he liked the view.
"He liked this chair because it gave him the front view of the door and he always used to tell us that, right ma," Pompey said.
Now that chair sits empty, and Jones' ashes rest atop the mantel.
"You're at peace now, no more worries, just peace," Jones' wife, Margaret, said while looking at the mantel.
Jones died on October 13, 2015 at the age of 71.
His death still haunts his wife and daughter.
"None of us know if it was really his time," Pompey said
Five days before his death, Jones went to Glenburnie Rehabilitation and Nursing Center for rehab on his leg after a stroke.
"We were like great, that's good, they're going to get him all straight, and he will be ready to come home," Pompey said.
But, Jones never came back home.
"It blindsided us," Pompey said.
According to state and federal inspection records, Jones complained of abdominal pain at 3:26 p.m. on October 12.
An X-ray was ordered, which revealed an ileum type pattern, which is a serious condition affecting the bowels.
The doctor ordered milk of magnesia, a probiotic, and anti-nausea medicine.
But, between 8 and 9 p.m. that night, according to the inspection records, a nurse said that Jones vomited a substance with a faint stool odor.
That nurse claimed a doctor was called and his vitals were checked.
That's where his daughter alleges the facility made its first mistake.
"We weren't told that ahead of time, we weren't called and told he had been vomiting stool," Pompey said.
She said her mom, who was her dad's responsible party, was never notified of her dad's change in condition, and the inspection reports show that too.
"We would have been up there, we would have been up there right away and demanded he go to the hospital," Pompey said.
Inspection records show Jones, again, vomited something brown colored with a faint stool odor around 10:30 or 11 p.m.
But, once again, he was not sent to the hospital.
"Vomiting stool is not OK by any means," Pompey said.
Records show the on-call doctor told investigators he could not remember exactly if he was informed that Jones was vomiting stool.
He said if he had known, he would definitely have sent him to the hospital.
Finally, around 1:20 or 2 a.m., when Jones again vomited something brown with a stool odor, the on-call doctor ordered that he be sent to the hospital.
Jones never made it there.
"We sat here waiting, and I just broke out crying and hollering oh my god," Margaret Jones said.
Inspection records show EMTs found Jones at 2:50 a.m. face down on the floor of his room.
He died a short time later when his heart stopped beating.
"We don't believe anybody took his condition seriously," Pompey said.
The family ended up filing a complaint, which led to a joint state and federal inspection.
Those records show that investigators found Glenburnie staff failed to notify the doctor in a timely manner when the resident vomited stool, which resulted in a delay in treatment.
Inspectors cited Glenburnie for non-compliance five times.
Some of those citations pertained to other residents at the facility.
"The investigator went in and they validated all of our complaints," Pompey said.
According to the state, Glenburnie submitted a plan of correction and when inspectors went to re-evaluate a couple of months later, they cleared all of the deficiencies.
While Pompey admits her dad had a host of medical issues, from diabetes to prostate cancer, she still struggles with the “what ifs” of what happened.
"We are saying had they called us, and let us know something was going on that day, the outcome could have been different," Pompey said. "He might have made it to a hospital, we might have could have even been there instead of him dying on a cold floor in a nursing facility."
CBS 6 investigative reporter Melissa Hipolit visited Glenburnie but she was told the administrator could not speak to the media.
The facility sent her the following statement instead:
"The staff of Glenburnie Rehabilitation and Nursing Center are professionals who care for their residents with dignity, compassion and diligence.
Day in and day out they work tirelessly to make the residents as comfortable as possible and help them to rehabilitate and restore lost function.
We object to any reference that suggests otherwise.
With regard to any specific case, the Center's obligations under the Health Insurance Portability and Accountability Act (HIPAA) prohibit the Center from sharing any protected health information about Mr. Jones.
As a result, the Center cannot discuss the care or treatment provided to any current or former resident of the Center as their privacy rights are protected as a matter of law."
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