Regarding Allegation #1: this investigation revealed that based on a review of Resident #1’s chest x-rays (between 10/31/22 and 05/04/22), Resident #1’s bilateral rib fractures occurred at the facility on at least two (2) occasions: once between 11/03/22 and 03/14/22 and once between 03/14/22 and 05/02/22. Witness #5 explained that these fractures did not look acute at the time of imaging; but beyond this, it is not possible to say how old they are, and that Resident #1 was more susceptible to a fracture because of the resident’s osteopenia (bone loss) and there were a multitude of possible causes for these fractures - outside of physical abuse; including coughing and falling. Per Witness #5, Resident #1’s fractures are not concerning for abuse because rib fractures are common among the elderly and bilateral rib fractures typically mean separate points of impact; such as, from falling more than once. Witness #10 did not feel that Resident #1 required a higher level of care than routine. [A review of R1’s physicians report (dated 10/23/21) does not document that the resident is a high risk for falls; however, a review of R1’s Resident Appraisal (dated 04/29/22) documented R1 is a fall risk. A review of R1’s Enhanced Residential Care Services Need Tier Assessment (dated 10/27/21) documented an annual fall-risk assessment.] Interviews conducted of seven (7) facility staff members, the majority corroborated that they have not observed a facility staff member physically abuse the resident or a resident in care. Interviews conducted of four (4) residents, the majority corroborated that they have not been nor have they observed residents in care being physically abused by a facility staff member. Interviews conducted of fourteen (14) witnesses, the majority corroborated that they did not suspect facility staff were physically abusing Resident #1 and that the resident was not in imminent danger at the facility; as the facility was providing the basic care necessary. Witness #4 stated that a visit from the L.A. County DHS Nursing Team conducted on 05/20/22 found no signs of abuse nor complaints from the residents in care. [A review of facility staff training records documented completed training courses on the topics: “Needs & Services Training for Resident #1” was provided on 04/28/22, “Mandatory Reporting” was provided during their hiring process, and “Personal Rights” was provided on 10/11/22].

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PHYSICAL ABUSE: Resident sustained fractures while in care is found to be UNSUBSTANTIATED.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PHYSICAL ABUSE: Staff physically abused resident while in care is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1 (S1: Christian Galas, Caregiver A.M.)