complaint·April 4, 2024

***report continues from LIC9099*** On 7/02/23 R1 was observed to be below baseline behavior and was noted to have not eaten anything for 2 days. Facility staff called 911 and R1 was taken to San Leandro Hospital where he remained until returning to the facility on 7/08/23. Allegation: Resident sustained unexplained bruises from suspected abuse. Interviews with memory care staff revealed that while giving R1 his “bed baths” none of the staff observed any bruises, marks, or burns on R1. Staff also stated that R1 did not show any signs of pain from any type of fracture. Allegation: Facility staff neglected resulting in resident being severely dehydrated . Based on interviews and records R1 became depressed when W1 told him that he would be going out of town. Memory care staff attempted to feed R1 for 2 days (6/30 and 7/01/23) but he refused. On 7/02/23 R1 appeared weak and lethargic and refused to get up out of bed. 911 was called and R1 was sent out to the hospital. R1 was discharged back to the facility on 7/08/23. Allegation: Lack of supervision resulting in resident sustaining multiple fractures. At the time of admission R1 refused to let Pacifica staff perform a body check. Several small scratches were noted on R1’s elbow. W1 stated that he thought R1 was abused at his previous facility but didn’t provide any further details. While R1 was hospitalized (July 2-8, 2023) an x-ray was done. The x-ray revealed several fractures: a recent to semi-recent fracture on the right side of R1’s pelvis. This could have been caused by an incident at the facility where R1 slid down out of his wheelchair and ended up on the floor in a seated position. No hospital visit was made on that date, so the injuries are unknown. The x-ray also revealed that there was an old fracture to R1’s left collarbone and an older fracture to his lower back (T12 vertebra). The fractures were noted as “age indeterminate” meaning it was unclear how old these fractures were. ***report continues on LIC9099C*** ***report continues from LIC9099C*** Allegation: Staff did not observe change of condition in resident Staff notes from R1’s file indicate that staff were documenting R1’s declining condition in late June and early July 2023. Staff also attempted to reach W1 to inform him but staff reported that W1 was difficult, at times, to get in touch with. The Department has investigated the complaint alleging resident sustained unexplained bruises from suspected abuse, facility staff neglected resulting in resident being severely dehydrated, lack of supervision resulting in resident sustaining multiple fractures and staff did not observe change of condition in resident. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.