complaint·April 3, 2026

[CONTINUED FROM LIC 9099] 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. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] Interviews of multiple facility staff and P1 aligned to show that R1 seemed normal over the next several days; R1 ate their meals in the dining room and act/spoke as usual. Per interview of P1: They spoke to R1 via phone on 03/27/2025, telling CCLD that R1 sounded “fine” that day. Then on 03/28/2025, P1 transported/escorted R1 to run errands outside the facility, and for the first time P1 noticed a change/decline in R1; specifically, P1 witnessed R1 struggle with separating their personal checks from the carbon copies, which was unlike R1. P1’s observation was communicated to facility staff the next day on 03/29/2025. Upon receiving this information, facility medication technician Staff #4 (S4) and nurse manager Staff #5 (S5) went to observe R1, finding that R1 was alert and speaking, but also confused (compared to their baseline). Facility mediation technician Staff #6 (S6) measured R1’s blood pressure at this time, finding it abnormally high at 251/102. Staff timely arranged for R1 to be transported to a local hospital emergency room (ER) via ambulance. Hospital ER records showed: The first computed tomography (CT) scan of R1’s head on 03/29/2025 (soon after R1’s arrival to the ER) showed “no acute findings” and “no traumatic findings.” Hospital staff wrote that R1 was overall alert and oriented at that time. R1’s new diagnoses on 03/29/2025 were “Hypertensive Emergency” and “Elevated Troponin I,” the latter of which was the likely explanation for R1 shortness of breath. [According to the National Institutes of Health, elevated Troponin I “in the context of hypertension signals significant myocardial strain, stress, or damage” and “represents a marker of severe, acute stress on the heart muscle” and increased risk of mortality.] A subsequent CT scan of R1’s head performed on 03/30/2025 showed “extensive new intraparenchymal, subarachnoid, and intraventricular hemorrhage.” ER records showed R1 experienced a stroke around 8:00 PM on 03/30/2025; this was the first time during this hospitalization that R1 was diagnosed with “Acute Stroke,” after which point R1 was transferred to the hospital’s intensive care unit and put on ventilator support. R1 was diagnosed with “Nontraumatic Cerebral Intracerebral Hemorrhage, Multiple Localized” starting 03/31/2025. R1’s was diagnosed with “Nontraumatic Cerebral Intraventricular Hemorrhage” starting 04/01/2025. R1 was diagnosed with “Acute Respiratory Failure” and “Altered Mental Status” starting 04/01/2025. R1 remained minimally alert/responsive, ventilated, and on nasal-gastric feeding tube in the ICU, until their death on 04/25/2025. According to their official death certificate, R1’s immediate cause of death was “Acute Respiratory Failure,” secondary to “Nontraumatic Cerebral Intraventricular Hemorrhage” and “Hypertensive Emergency.” There was no involvement from the San Diego County Medical Examiner’s office in this case. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] Academic research for this case showed: A headache, in and of itself, does not reliably indicate external trauma. A headache can have another internal physiological basis, such as hypertension. Confusion, in and of itself, does not reliably indicate external trauma. Confusion can have another internal physiological basis, such as hypertension. According to the Cleveland Clinic, “Hypertensive encephalopathy is brain dysfunction caused by extremely high blood pressure,” of which headache and confusion are both hallmark symptoms, and “most adults who experience hypertensive encephalopathy enter the emergency room with a dangerously high reading greater than 220/130 mmHg, but it could sometimes occur with blood pressure readings as low as 160/100 mmHg.” According to the National Institutes of Health, an intracerebral hemorrhage is “a severe type of stroke occurring when a ruptured blood vessel causes bleeding inside the brain, creating pressure, destroying brain tissue, and blocking oxygen,” and “it is often caused by chronic hypertension.” The NIH also reports, “Hypertension is the most common cause of spontaneous, primary intraventricular hemorrhage (PIVH) in adults, with high blood pressure causing small vessels to rupture. It typically presents with sudden headache, nausea, and altered consciousness.” With the available evidence, the Department concluded: R1’s fall on 03/22/2025 was not a proximate cause of R1’s elevated blood pressure; hypertension was a preexisting chronic condition for R1. While R1 arrived at the ER in a state of hypertensive crisis on 03/29/2025, R1’s stroke/cerebral hemorrhage occurred the following day while R1 was under hospital care (and not at the facility). Hospital staff determined R1’s stroke/cerebral hemorrhage was “nontraumatic,” meaning R1’s earlier fall on 03/22/2025 was not a proximate cause for the stroke/hemorrhage’s occurrence (8) days later, on 03/30/2025. The “nontraumatic” nature of the stroke/cerebral hemorrhage was reiterated on R1’s official death certificate. The available evidence does not support that the 03/22/2025 fall itself caused R1 pain or injuries warranting immediate hospital care on that date, or on successive days. The available evidence cannot prove that R1’s blood pressure was elevated during their fall on 03/22/2025, or on the successive days between the fall and 03/28/2025, or that Licensee’s staff had constructive knowledge of R1’s elevated blood pressure for which they also failed to timely respond to. Based on records and interviews, a preponderance of evidence does not exist to prove Licensee culpability in R1’s death, or that Licensee did not arrange timely medical care for R1. Both allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Executive Director Diana Weinstein, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.