Elsie Fossum checked herself into the Claremont Place assisted living facility in Southern California. She thought she'd be safe. Instead, the 95-year-old died from injuries she got at the Pomona assisted living facility. Seven years later, her family is still waiting for answers from investigators at the California Department of Public Health.
"You figure they're going to find something if there's something there, not that they'd just put the thing away and forget about it eventually," said her nephew Jim Fossum.
The facility said Elsie died from injuries she got when she fell down.
"It wasn't the result of a fall, that was punching," said Beverlee McPherson, the former nursing director at Claremont place.
"Her face looked like Mohammed Ali did a dance on it. And you could see knuckles. Her eyes were so badly swollen and just hanging. She was miserable, it was very sad to see," said McPherson.
McPherson believes someone working at Claremont Place was responsible for Elsie's injuries.
The Los Angeles County Coroner's report concluded that allegations of assault could not be ruled out, but no charges have been filed. McPherson says she was fired from Claremont place for unrelated reasons. Claremont Place is now under different administration. It declined to comment for this story.
Elsie Fossum's family isn't alone in waiting for answers.
Yearly investigation totals obtained by the Center for Investigative Reporting from the Department of Public Health shows there was a steady increase in outstanding complaint cases that weren't being pursued at the time she died.
Documents show state regulators effectively shelved more than 900 cases from Southern California, including the most alarming allegations that involve suspicious deaths.
Marc Parker believes that's because investigators weren't doing their jobs. Parker worked at the department for 24 years. He oversaw investigations at the Department of Public Health at the time of Elsie's death. He inspected the regional office and says what he found was chaos.
"I was appalled. There were hundreds and hundreds and hundreds of unassigned, uninvestigated complaints in file drawers," said Parker.
Then, Parker says his superiors at the department pressured him to close cases quickly. They were ordered to wrap up at least 10 cases a month.
Parker says he retired early because he could no longer tolerate the dysfunction in the department.
Dr. Ron Chapman took over the Department of Public Health in 2011. He admits the department's investigations section was poorly managed, but he says now they're making changes.
"And a backlog for investigating complaints is inexcusable, should not have occurred. We've made lot of progress since then. So today, any complaints that come in, they're being screened within 48 hours and we're not building a backlog today," said Chapman.
The yearly investigations totals analyzed by the Center for Investigative Reporting shows the backlog has been reduced.
But former chief investigator Marc Parker says the new policy discourages investigators from visiting the scene of potential crimes. Instead, investigators do most of their work over the phone.
"If you don't go eyes on, interview people directly, talk to people directly; you're going to miss huge amounts of information. And that places the public at risk," said Parker.
In fact, department data shows that most investigations don't result in action against caregivers. The number of caregivers' licenses revoked has gone down and fewer cases have been referred for prosecution.
The department defends its policy. But Chapman admits he is troubled that fewer cases are being referred for legal action.
"We don't understand that decline in numbers. It's very concerning to me, and we're looking into it," said Chapman.
That's little comfort to the family of Elsie Fossom. Her case was lost in a pileup of healthcare abuse cases at the Department of Public Health. Her case was passed through different state agencies -- even the local police.
Despite questions surrounding her death, the Department of Health closed Fossom's case in February. Seven years after she died.
In an email, the department admits it should have "identified this allegation as a high priority," and says "we regret that did not happen."
Chapman says he'll personally be looking into Elsie's case.
Jim Fossum hopes the agency will step up and investigate abuse cases thoroughly, not only for his aunt, but for everyone.
"You know as we baby boomers get older, there's more and more people that are going to be living in these types of facilities and you've got to have decent agencies that monitor these situations," he said.
The Los Angeles County Sheriff's Department has decided to take a closer look at Elsie's Fossum's death. It has opened a homicide investigation.
Written and produced by Ken Miguel