Facility Evaluation Report

09/19/2024 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Nora Serrano. The purpose of the visit was to deliver the results of a case management investigation.

Hospital medical records revealed that Client 1 (C1) suffered an avulsion fracture of the left hip consistent with an unwitnessed fall.

C1 received one to one care at Pine Ville Care Home (facility). Staff 1 (S1) was C1’s caregiver in the time period around the time of the injury. S1 denied any rough handling of C1 at any time. S1 also denied C1 had a fall the night of the incident and that C1 never screamed out in pain that day.

Several facility staff described S1 as a lazy worker who would consistently yell at C1 and ignore C1’s cries for help. Facility staff all agree that S1 would routinely conduct improper transfers with C1 which would result in C1 acting out aggressively toward S1.

Clients in care were consistent in stating S1 was mean to C1 on a regular basis. Client 2 (C2) remembered seeing C1 on the floor in their room before dinner the day before C1 was sent to the hospital. C2 stated S1 was with C1 in their room and assisting C1 back into their wheelchair.