Instructions

In the next few pages, you will be asked about information regarding the injured person’s medical providers, hospitalizations and facilities they lived at. This includes the nursing home / assisted living facility which we are investigating. It is important to fill out every section so that we may properly investigate your case.

Please note, you are asked to go back 5 years, listing all medical providers and facilities that the injured person treated with/at.

Medical Providers

Your Information

Who you are, what case this involves
Name of the injured person

Nursing Homes / Assisted Living Facilities

This is where you list all of the nursing homes / assisted living facilities your loved one has lived at. Skip to the bottom and click "Move on to Hospitals" if your loved one did not live in a nursing home or assisted living facility.
What is the name of this facility?
Was this facility a nursing home or an assisted living facility (including memory care units)?
Who is the doctor that cared for residents at this facility?
When did your loved one live in this facility? If you do not know the exact dates, please specify which month and year they entered the facility and the month and year in which they left.
What is the reason your loved one went to a nursing home or assisted living facility? For example, their dementia worsened, they had Parkinson's, or they needed rehabilitation after a stroke.
Facility Address
Street Address
Apt. No. / Suite No.
City
State/Province
Zip/Postal
Country
If you do not know the full address, fill out the sections you do know.
Who was the Director of Nursing while your loved one lived at this facility? If there was a change in directors, name all the directors you remember.
Enter the name of the facility's administrator. List the names if there were multiple administrators and also note if there was a period of time where the facility did not have an administrator.
Who took care of your loved one at this facility? List anyone you remember, good or bad workers. Add people whose names you know and a description of what they look like (especially if you do not know their last name).
Is there anything else we should know that would be pertinent to the investigation? For example the injured person lived at the nursing home for 2 years and they were hospitalized for a month then returned to the same nursing home. Another example is that the nursing home changed ownership during the course of care.
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