complaint·October 30, 2025

The complaint alleged that R1 expired after sustaining a serious injury due to the fall while in care. According to the IB investigation, fire department records confirmed that on 12/06/2024, staff called 911 to request medical assistance for R1, who sustained a fall while being assisted in the bathroom. Staff interviews indicated they followed facility protocols for falls, including assessing R1, requesting medical attention, and monitoring R1 until emergency services arrived. On December 6, 2024, R1 was admitted to the hospital and diagnosed with a displaced distal femur fracture from a mechanical ground-level fall, which required surgery. R1 was discharged from the hospital on December 17, 2024, in stable condition and transferred to a skilled nursing facility (SNF). IB Investigator Torre’s review of R1’s death certificate indicated that R1 expired on January 22, 2025, while under care at the SNF. The immediate cause of death was listed as cardiopulmonary arrest (within minutes), with contributing conditions of Alzheimer’s dementia (within years) and cancer. Based on the investigation conducted by the IB Investigator and review of the medical records, there is insufficient evidence to support the allegation that R1’s death was the result of a serious injury sustained while in care at the facility. Therefore, the allegation “Questionable Death” is deemed Unsubstantiated at this time.