complaint·January 13, 2023

The following documents were collected which included: staff and resident roster, R1's resident information/emergency contact sheet, physician report dated on 10/12/21, preplacement appraisal information, physician/healthcare provider order sheet and care profile. The complaint was referred to the CCL IB investigation Unit and assigned to IB Investigator Garcia for full investigation. IB investigator Garcia conducted and completed the investigation which included interviews with the facility administrator, resident’s relative, facility residents, six facility staff, resident’s physical therapist. IB Investigator Garcia also obtained Hospital Record, police report and facility progress notes. The investigation revealed of the following: Regarding the allegation of “Resident sustained a fracture while in care.” The investigation revealed that facility caregiver was rough handled R1. After interviews with administrator and facility staff, it was reported that R1 had ongoing medical issues and was in and out of the skills nursing facility and it was not sure if R1 sustained the rib fracture at the skilled nursing or had previously fallen. Per review of medical reports, it stated that there’s no evidence of suspected abuse or neglect was deemed at the times of the medical evaluations. The facility staff reported caregiver may be had a stern personality or being rush since facility had short staff but never witnessed any physically abusing or neglect to the residents. Therefore, based on the interviews and statement provided, there’s no sufficient evidence to support the allegation of resident sustained an unexplained fracture while in care. Therefore, LPA finds the allegation to be 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 allegation is UNSUBSTANTIATED. An Exit Interview Conducted and a copy of the report and appeal right was provided to Administrator Barbara Tyler.