Complaint Investigation Report

The Complainant stated on 03/22/2025, R1 fell and their head contacted the ground. They said R1 had a subsequent decline in cognition, but Licensee’s staff did not arrange for R1 to go to the hospital until 03/29/2025. They said R1 remained in the hospital’s Intensive Care Unit (ICU) until R1 died on 04/25/2025.

According to their LIC603 Preplacement Appraisal, R1 was already diagnosed with hypertension and hyperlipidemia when they moved into the facility. R1’s LIC602 Physician’s Report showed that both such diagnoses were chronic and preexisting for years before the above fall. R1’s medical records corroborated these same diagnoses and showed R1 had prior history of cerebrovascular accident (aka “stroke”). R1 last met with their primary care physician on 01/06/2025 (over 3.5 months before the above fall); on that date R1’s elevated blood pressure (which was 190/51), along with “complex conditions case management,” was the treatment focus of said doctor's appointment. Together, records and interviews showed that during the complaint timeframe: R1 was and remained independent in all their activities of daily living (ADLs), including mobility, transferring, and medication management. R1’s doctor wrote that R1 was not confused/disoriented, was able to follow instructions, and was able to communicate their own needs. While some of R1’s prescribed medications at the time treated/related to high blood pressure, R1 was not on any blood-thinner type medications during the complaint timeframe.

Records and interviews showed: On 03/22/2025 around 7:50 PM, R1 was carrying food/groceries when tripped and fell, landing on the welcome mat just outside the facility’s main entrance door. The fall was partially witnessed by Person #1 (P1). Receptionist Staff #2 (S2) observed R1 on the ground, right after the fall, and radioed caregiver Staff #3 (S3) for help. S2 and S3 went outside to assist R1. R1 quickly got back up on their feet, with S3’s help. R1 insisted to these staff that they were fine/uninjured and declined to be evaluated by the medication technician on duty, Staff #3 (S3). Neither P1, S1, nor S2 observed any skin tear, mark, or bruise on R1’s head or body. Neither R1 nor P1 claimed to these facility staff, at that time, that R1 had head contact during the fall. S2 then escorted R1 back to their apartment/room. According to P1, they phoned R1 around 8:30 PM, at which time R1 told P1 they had a headache for which they would take a Tylenol. Neither P1 nor R1 mentioned R1’s headache to facility staff.