complaint·April 11, 2024

Based on interview conducted with Investigator 1 (I1), I1 states that both the Fremont Fire and Police Departments concluded R1’s death as a result of medical history and the doctor concurred. I1 stated that I1 was not aware of any bruises on R1’s face. I1 stated that many elderly people will have bruising at the time of death but it’s not necessarily an indication of foul play or neglect. The bruise can change rapidly after the time of death and with medical intervention. R1 had 30 minutes of CPR without being revived. I1 stated that alone can affect the appearance of the bruise. Unless there is a large wound or lots of swelling, a bruise would not likely trigger further investigation by the coroner’s office. A review of R1’s Reassessment dated April 1, 2023 indicates R1 needs reminders to change clothes into clean clothing 2x a day, escorting and/or physical assistance to attend meals only, self manages during the day but requires assistance to/from the bathroom at night and medication assistance. A review of the facility’s Resident Communication Log dated 7/2 – 7/3, 2023 indicates R1 was checked by S1 at 12:30 am and 2:00 am. The next check was conducted at 5am when S1 found R1 unconscious and unresponsive. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. A copy of this report was provided to the Velayo.