Family Lives

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on records reviewed and interviews, for one of three sampled clients (Client #1), the Agency failed to ensure Client #1’s personal property was treated with respect, when on 09/21/2025, Nurse #1 destroyed some of Client #1’s medical supplies and threw them in the trash, all of which was captured by a motion-activated (automatically starts recording video only when its sensors detect movement) surveillance camera that had been installed in Client #1’s room by concerned family members. Findings include: The Home Health Care Services Policy titled Patient Rights, undated, indicated Home Health Care Services promotes and protects the exercise by its patients of their rights, including the right to be free of misappropriation of personal property by anyone furnishing services on behalf of Home Health Care Services. Review of Client #1’s Medical Record, indicated Client #1 was admitted to the Home Health Care Services in June 2006 and his/her medical diagnoses included Larsen Syndrome (a rare genetic condition affecting bone and joint development, causing multiple dislocations at birth, plus issues like clubfeet, spinal problems, short stature, facial differences and sometimes hearing loss), Respiratory Failure (a condition where lungs fail to perform gas exchange, leading to low blood oxygen or high blood carbon dioxide), Gastrostomy (a procedure to create a direct opening from the outside of the abdomen into the stomach, using a tube (G-tube) to deliver nutrition, liquids, and medications), Congenital Limb Anomaly (a baby is born with arms, legs, fingers, or toes that are missing, not fully formed, or shaped differently, resulting from issues during fetal development in the womb) and Quadriplegia (paralysis affecting all four limbs (arms and legs) and the torso, resulting from damage to the cervical (neck) spinal cord or brain, causing loss of movement and sensation below the injury level, impacting daily life significantly and sometimes requiring breathing support). Review of Client #1’s Home Health Certification, Plan of Treatment and Medical Update Certification Period August 2025 to October 2025, indicated Client #1 is non-verbal, has global development delays and is not capable of either directing or participating in his/her own care. The Medical Update indicated Client #1 is unable to participate in his/her care secondary to being a Quadriplegia and is totally dependent on all his/her Activities of Daily Living (are fundamental self-care tasks essential for independent living, including bathing, dressing, toileting, transferring (moving), continence, and feeding). The Home Health Care Services Incident and Accident Report, dated 09/21/25, indicated that on 09/21/25, Nurse #2 informed Clinical Director #2 that Nurse #1, who had provided Nursing Services to Client #1 from 10:00 P.M. on 09/20/25 until 7:00 A.M., into 09/21/25, had destroyed some of Client #1’s medical supplies and that she (Nurse #2) was made aware of what had occurred based on the review of video surveillance camera footage from the camera that had been installed in Client #1’s bedroom and shown to her (Nurse #2) by a Family Member. The Report indicated the video footage confirmed Nurse #1, destroyed some of Client #1’s new, unused briefs (adult diapers with adhesive tabs for managing bladder/bowel leakage), while providing Services to Client #1 that night, The Report also indicated that on 09/21/25, Client #1’s Primary Caregiver notified the local Police to inform them of Nurse #1’s destruction of property while providing care to Client #1 The Report indicated Nurse #1 was immediately suspended and subsequently her employment was terminated after Agency Management Staff reviewed the video surveillance camera footage (that captured Nurse #1’s treatment of Client #1). The Surveyors (#1 and #2) reviewed the video surveillance camera footage with the Agency’s Chief Executive Officer, the video footage, dated 09/21/25, was of Client #1, who was in bed, and captured Nurse #1’s interaction with Client #1 during the 10:00 P.M. on 09/20/25 to 7:00 A.M. into 09/21/25 shift as follows: -06:46:45 – Nurse #1 walks away from Client #1’s bed, walks towards the doorway (between Client #1’s room and adjoining room), looks to her right (trash located behind Client #1’s white cabinet wall), stops, turns around quickly goes into Client #1’s white cabinet draw. Nurse #1 pulls out a new package of incontinence briefs; Nurse #1 goes back through the doorway and throws the briefs in the trash. During telephone interview on 12/17/25 at 7:22 P.M., Nurse #2 said she arrived to work at Client #1’s home on 09/21/25, at 7:00 A.M., and after Nurse #1 left, Client #1’s Primary Caregiver approached her distraught and alleged Nurse #1 had destroyed some of Client #1’s medical supplies. Nurse #2 said Client #1’s Primary Caregiver showed her the video surveillance footage (dated 09/21/25) from the camera installed in the Client #1’s bedroom, in which Nurse #1 takes a new package of incontinence briefs out of Client #1’s dresser cabinet, rips up the briefs and throws them away in the trash. Nurse #2 said she had noticed Client #1’s medical supplies started to become low more often and that she did not understand what was happening to them. Nurse #2 said recently during one of her shifts, Client #1’s Primary Caregiver had to go through the trash to obtain Client #1’s vital signs that were thrown out accidentally prior to being documented, and said Client #1’s Primary Caregiver came across new, unused, catheters (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder for removing fluid) stuffed in the trash when trying to recover Client #1’s vital signs. Nurse #2 said Client #1’s Primary Caregiver informed her she had started to check the trash after each Nursing shift. Nurse #2 said Client #1’s Primary Caregiver said they had narrowed it down to Nurse #1, and that the camera footage confirmed Nurse #1 destroyed and threw away new and unused medical supplies. During telephone interview on 12/17/25 at 12:44 P.M., Clinical Director #2 said on 09/21/25, she spoke to Nurse #2 around 12:15 P.M. who was upset. Clinical Director #2 said Nurse #2 reported that she had reviewed Client #1’s video surveillance camera footage, dated 09/21/25, with Client #1’s Primary Caregiver, which captured Nurse #1 destroying Client #1’s medical supplies. Clinical Director #2 said Nurse #2 reported that Client #1’s medical supplies were not opened, were unused, and Nurse #1 was throwing the supplies away for no reason. During interview on 12/16/25 at 11:00 A.M., the Chief Executive Officer said on 09/21/25, around 12:30 P.M., she was informed by Clinical Director #2 and had also spoken to Nurse #2, who reported that Client #1’s Primary Caregiver of alleged that Nurse #1 had destroyed some of Client #1’s supplies, and that Nurse #1 had been caught doing so on video surveillance camera footage. The Chief Executive Officer said on 09/21/25, she arrived at Client #1’s home around 5:15 P.M. and reviewed the video surveillance camera footage with Client #1’s Primary Caregiver. The Chief Executive Officer said she notified the Board of Registration in Nursing regarding Nurse #1’s destruction of Client property while providing care to Client #1 and Nurse #1’s employment with the Agency was terminated.”

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on records reviewed, interviews and review of motion-activated (automatically starts recording video only when its sensors detect movement) surveillance camera video footage, for one of three sampled clients (Client #1), the Agency failed to ensure Client #1 was free from abuse when it was reported that on 09/21/25, Nurse #1 was physically abusive during the provision of care and neglected him/her when she did not provide all the Skilled Nursing Services he/she required, all of which was captured on the surveillance camera in Client #1’s room. Findings include: The Home Health Care Services Policy titled Neglect, Misappropriation, and Abuse Reporting, undated, indicated Neglect is the failure to provide goods and services to an individual that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; Neglect includes failures by individuals to support the physical, emotional, and social needs of adults dependent on others for their primary care. The Policy indicated Abuse is either the non-accidental commission of any act by a caregiver which causes or creates a substantial risk of physical or emotional injury; Emotional Abuse includes insults, yelling or threats of harm and/or isolation, or non-verbal actions such as throwing objects or glaring to project fear and/or intimidation, and Physical Abuse includes slapping, hitting, beating, bruising or causing someone physical pain, injury or suffering. Review of Client #1’s Medical Record, indicated Client #1 was admitted to the Home Health Care Services in June 2006 and his/her medical diagnoses included Larsen Syndrome (a rare genetic condition affecting bone and joint development, causing multiple dislocations at birth, plus issues like clubfeet, spinal problems, short stature, facial differences and sometimes hearing loss), Respiratory Failure (a condition where lungs fail to perform gas exchange, leading to low blood oxygen or high blood carbon dioxide), Gastrostomy (a procedure to create a direct opening from the outside of the abdomen into the stomach, using a tube (G-tube) to deliver nutrition, liquids, and medications), Congenital Limb Anomaly (a baby is born with arms, legs, fingers, or toes that are missing, not fully formed, or shaped differently, resulting from issues during fetal development in the womb) and Quadriplegia (paralysis affecting all four limbs (arms and legs) and the torso, resulting from damage to the cervical (neck) spinal cord or brain, causing loss of movement and sensation below the injury level, impacting daily life significantly and sometimes requiring breathing support). Review of Client #1’s Home Health Certification, Plan of Treatment and Medical Update Certification Period August 2025 to October 2025, indicated Client #1 is non-verbal, has global development delays and is not capable of either directing or participating in his/her own care. The Medical Update indicated Client #1 is unable to participate in his/her care secondary to being a Quadriplegia and is totally dependent on all his/her Activities of Daily Living (are fundamental self-care tasks essential for independent living, including bathing, dressing, toileting, transferring (moving), continence, and feeding). The Home Health Care Services Incident and Accident Report, dated 09/21/25, indicated on 09/21/25, Nurse #2 informed Clinical Director #2 that Nurse #1, who had provided Nursing Services to Client #1 from 10:00 P.M. on 09/20/25 until 7:00 A.M. into 09/21/25, had abused and neglected Client #1 during the overnight shift and that it was captured on a surveillance camera that had been installed in Client #1’s bedroom. The Report indicated Nurse #2 was shown the video footage by Client #1’s Primary Caregiver. The Report indicated the video footage confirmed that Nurse #1 was captured on video sleeping, seen being physically abusive with Client #1 and the Nurse #1 neglected to provide adequate and appropriate skilled Nursing Services to Client #1 that night. The Report indicated on 09/21/25, Client #1’s Primary Caregiver notified the local Police to inform them that Nurse #1 had physically abused and neglected Client #1, had been seen sleeping, and had not provided care (as ordered) to Client #1. The Report indicated Nurse #1 was immediately suspended and subsequently her employment was terminated after the Agency Management Staff reviewed Client #1’s video surveillance camera footage, provided by the family. The Surveyors (#1 and #2) reviewed the video surveillance camera footage with the Agency’s Chief Executive Officer, the video footage, dated on 09/21/25, was of Client #1, who was in bed, and captured Nurse #1’s interaction with Client #1 during the shift as follows: -03:50:57 – Nurse #1 is sitting in a chair with another chair located directly in front of her, Nurse #1’s legs are propped up on the chair, her head is leaning towards the right side of her body against her right hand, her arm is in a bent position, elbow located on the chair arm, and Nurse #1 has a blanket covering her body and she is sleeping. -06:13:36 – Client #1 is in bed, positioned lying on his/her right side, left leg crossed over right leg, right leg is in a bent position, Client #1 has no clothing on from mid-section of abdomen to feet, is not covered with a least a sheet for dignity, and coiled medical tubing can be seen laying across Client #1’s face. -Nurse #1 is seen watching television while providing hygiene care to Resident #1. Nurse #1 pulls on incontinence brief out from under Client #1. Nurse #1 walks away from Client #1, without covering Client #1. -06:14:39 – Nurse #1 picks up Client #1’s arm off the bed, raises his/her arm to the height of the bed rail and then let’s go quickly of Client #1’s arm, causing Client #1’s arm to fall onto the bed without support or assistance. Nurse #1 continues to watch television and then walks away. -06:14:51 – Nurse #1 walks over to Client #1’s dresser cabinet located across the room. Nurse #1 removes a blue Chux (absorbent disposable pads typically placed under a client as protection due to incontinence) from the dresser drawer, proceeds to walk over to Client #1 and throws the Chux on Client #1’s bed hitting his/her legs. Nurse #1 walks away, Client #1’s body continues to be uncovered, and Nurse #1 walks towards Client #1 once again and throws a brief on Client #1’s bed hitting his/her legs. -06:15:59 – Client #1 continues to be uncovered in bed, lying on his/her right side with his/her left leg over his/her right leg that is in a bent position. Nurse #1 then proceeds to lower the head of the bed into the flat position. -06:17:22 – Nurse #1 rolls Client #1 over on to the right side of his/her bed (Nurse #1’s back towards the camera). Client #1 is against the right side bed railing; Nurse #1 places a chux under Client #1 and then Nurse #1 proceeds to turn Client #1 onto his/her back as Client #1’s left arm falls onto his/her bed, his/her arm is in a twisted outward position, but Nurse #1 does not reposition the arm. -Nurse #1 then places her right hand on Client #1’s chest, then uses her left hand to push on Client #1’s abdomen, which results in Client #1’s body going further onto his/her back, positioning Client #1 closer to the left side bed railing. Nurse #1 tugs at and pulls the Chux towards her, while placing her left hand onto Client #1’s abdomen to push on him/her, Nurse #1 then uses her right hand to push on Client #1’s abdomen to move him/her more to the left side of the bed (repeats motion). Nurse #1 places her right hand under Client #1’s back and her left hand under Client #1’s legs and swings both legs towards her quickly, while Client #1’s upper body moves slightly. -06:18:39 – Nurse #1 takes her left hand places it on Client #1’s right arm and pulls Client #1’s body towards her using Client #1’s arm. Client #1’s head of the bed continues to be in the flat position. -06:18:44 – Nurse #1 takes her right hand, places it on the top of Client #1’s head, Nurse #1 gathers Client #1’s hair with her fingers, holds onto Client #1’s hair with her hand, then proceeds to pull on and lift Client #1’s upper body off of the bed, still holding onto Client #1’s hair with her right hand and sits him/her up in a semi-sitting position. Nurse #1 continues to hold Client #1’s hair in her right hand and simultaneously using her left hand, flips over Client #1’s pillow, then still holding Client #1’s hair with her right hand, Nurse #1 pulls Client #1 back down into a laying position still holding onto Client #1’s hair, with only using her right hand. -It is important to note the only time Nurse #1 was seen wearing gloves in the video surveillance was at 6:13:36, she then removed her gloves at 6:20:37 and then proceeded to provide care to Resident #1. Nurse #1 was not seen washing her hands, did not change her gloves, she was seen touching equipment and then continued to provide care to Client #1. -06:20:47 – Nurse #1 continues to watch television while providing care to him/her, Nurse #1 takes her left hand places it on Client #1’s right arm/shoulder then places her right hand on Client #1’s right thigh, pushes him/her over onto his/her left side and Client #1’s right leg crosses over his/her left leg, Client #1’s tracheostomy is observed to be misaligned in an upward position over Client #1’s face and head. Nurse #1 is leaning over the right side of the bed railing watching television while performing Chest Physiotherapy (PT, a technique like percussion to help loosen and clear thick mucus in the lungs) on Client #1. -Nurse #1 takes her right hand, grabs Client #1’s left leg which is bent under his/her right leg, lifts Client #1’s left leg off the bed and pulls the leg towards her to move Client #1 body closer to her and then let’s go of the left leg, letting it fall onto the bed. Nurse #1 continues to perform Chest PT, while watching television and Client’s tracheostomy tubing continues to be in an upward position over Client #1’s face/head, with tubing lying on top of the right side of Client #1’s bed railing with his/her head of the bed in a flat position. -06:43:08 – Nurse #1 is on the right side of Client #1’s bed and grabs Client #1’s head from a laying position to sit Client #1 in an upward semi- sitting position. Nurse #1 is holding Client #1’s head between her armpit and forearm as she is working on Client #1’s tracheostomy collar/ties, Client #1’s head is bent forward, and Nurse #1 quickly places Client #1’s head on his/her pillow. Nurse #1 then places tracheostomy ties to the left side, the right side and then proceeds to position both of her hands around the Client #1’s neck to pull on and sit him/her up in an upward semi-sitting position, Client #1’s head is bent in a forward position and against Nurse #1’s chest as she is working on Client #1’s tracheostomy collar/ties and then she quickly places Client #1 head on his/her pillow. Client #1’s head of the bed continues to be in a flat position. -It is important to note that by this time, the head of Client #1’s bed has been flat for just about a half hour, this position was contraindicated based on Client #1’s care needs and medical condition. -06:44:30 – Nurse #1 is standing at the right side of the bed, takes her right arm, places her arm across the bottom of Client #1’s feet, to secure or hold down his/her feet, while using the adjustable bed remote to raise head of the bed in an upward position to somewhere around 80-90 degrees. -Nurse #1 then takes her right hand places it on Client’s left arm and with her left hand behind Client #1’s neck, Nurse #1 moves Client #1 away from his/her pillow, moves Client #1 in a forward position quickly, towards the left side of the bed, for Client #1 to be in the center of his/her pillow. Simultaneously, Nurse #1 takes her right hand which is located behind Client #1’s head then takes her left hand to flip over the pillow and can be seen touching Client #1’s tracheostomy. -06:45:22 – Nurse #1 is standing at right side of the bed, looking at Client #1, Nurse #1 leans her body inward to Client #1, raises her right arm/hand and is seen pointing her finger at and towards Client #1’s face, her finger is a few inches away from Client #1’s face, Nurse #1 moves her finger back and forth (twice) and Nurse #1’s lips can be seen moving. -Nurse #1 takes her right hand places it on Client #1’s left shoulder and pulls Client #1’s left shoulder forward and back quickly, then let’s go of Client’s shoulder. Nurse #1 then lifts her right hand a second time, points her finger towards Client #1 while she is looking at him/her, moves her finger back and forth, then moves her finger towards Client #1 face. -06:45:27 – Nurse #1 is standing on the left side of the bed, Nurse #1 takes her left hand, reaches over Client #1’s head, to move his/her head away from his/her pillow, Client #1’s head/neck is bent in a forward position. Nurse #1’s left arm/elbow is holding onto Client #1’s head while she is working behind Client #1’s head/neck. -06:47:07 – Nurse #1 approaches the right side of the bed, places her left hand on Client #1’s head and in her right hand she has a face cloth. Nurse #1 uses quick motions with the face cloth and rubs Client #1’s face in different directions (Client #1’s head is seen moving). Nurse #1 moves the washcloth to Client #1’s chin, holds it in the same position for a few seconds, shakes Client #1’s head to the right and left (small movements), Nurse #1 looks at Client #1 briefly, leans inward towards him/her and then continues to wash Client #1’s face quickly, applies lip balm to lips and then leaves Client #1’s bedside. -06:48:11 – Client #1 is in bed, continues to be on his/her back, blanket covering him/her, head of bed positioned in an upward position to around 80-90 degrees. Nurse #1 is standing on the right side of the bed. Nurse #1 places her right hand on Client 1’s trachea, her left hand is located near Client #1’s right side of his/her neck, she adjusts Client #1’s collar/ties with a quick motion and then Nurse #1 takes her hands, grabs the back of Client #1’s head and quickly pulls his/her head in a forward motion, causing his/her chin to touch his/her chest. Nurse #1’s arms rest on Client #1’s head, while she is quickly moving Client #1’s hair in an upward position to be able to see his/her neck. Nurse #1 then let’s go of Client #1’s head, Client #1’s head plops (was not lowered gently) onto his/her pillow. -06:48:28 - Nurse #1 takes her right hand, places it on Client #1’s chin and pushes Client #1’s chin inward, causing his/her pillow to be depressed inward, Nurse #1 pulls Client #1’s blanket down a little with her right hand, uses her left hand, positioned to the right of Client #1’s neck tracheostomy collar pulling towards her (Nurse #1) in a back and forth motion (twice), causing Client #1’s head to jerk to the right, forward and back. -06:49:41 – Nurse #1 puts her right hand directly on Client #1’s tracheostomy and pushes it inward, while Client #1’s head/neck is being pressed against his/her pillow, Nurse #1 then let’s go of Client #1’s tracheostomy, continues to work on his/her tracheostomy tubing and Nurse #1 then proceeds to grab the television remote. During telephone interview on 12/17/25 at 7:22 P.M., Nurse #2 said she arrived at Client #1’s home on 09/21/25, at 7:00 A.M., and after Nurse #1 left, Client #1’s Primary Caregiver approached her, she was distraught and was alleging Nurse #1 had abused Client #1. Nurse #2 said Client #1’s Primary Caregiver showed her footage from the video surveillance camera that had been installed in the client’s bedroom (dated 09/21/25). Nurse #2 said she saw as Nurse #1 positions Client #1 onto his/her side, that it looks like Nurse #1 sleeps on and off from 12:00 A.M. to 6:00 A.M., and that the camera turns on and captures Nurse #1 during the time when she awakens and begins to perform Client #1’s A.M. care. Nurse # 2 said in the video Nurse #1 is seen physically abusing Client #1, that Nurse #1 pulls Client #1 hair to sit him/her up in a sitting position, was rough while providing care and pulled on Client #1’s arm to move Client #1’s entire body. During telephone interview on 12/17/25 at 12:44 P.M., Clinical Director #2 said on 09/21/25, Nurse #2 called her around 12:15 P.M. who was distraught and upset. Clinical Director #2 said Nurse #2 said Client #1’s Primary Caregiver showed her the video surveillance footage from the camera installed in the Client #1’s room, dated 09/21/25, in which Nurse #1 is seen physically abusing and neglecting Client #1 and had been seen sleeping, not providing care to Client #1. During interview on 12/16/25 at 11:00 A.M., the Chief Executive Officer said on 09/21/25, she arrived at Client #1’s home around 5:15 P.M. and reviewed the video surveillance camera footage, dated 09/21/25, with Client #1’s Primary Caregiver. The Chief Executive Officer said review of the video footage confirmed Nurse #1 physically abused Client #1 and neglected to provide necessary Nursing Skills. The Chief Executive Officer said Nurse #1 had provided care to Client #1 for over 20 years, that Nurse #1 was educated on Client #1’s Plan of Treatment, what needed to be provided for Nursing Services to Client #1 and the Agencies Policies and Procedures. The Chief Executive Officer said she reported Nurse #1 for abuse and neglect while providing care to Client #1 to the Board of Registration in Nursing and reported Nurse #1 to the Disabled Persons Protection Commission and that the Agency terminated Nurse #1’s employment.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on records reviewed, interviews and review of motion-activated (automatically starts recording video only when its sensors detect movement) surveillance camera video footage, for one of three sampled clients (Client #1), the Agency failed to ensure Nursing provided services per Client #1’s Physician Orders, when video footage captured Nurse #1 sleeping, not following and not providing necessary skilled Nursing services in accordance with Physician orders. Findings include: The Home Health Care Services Policy titled Physician or Allowed Practitioner Guidelines, undated, indicated to ensure safe professional and legal practice, and quality care, Home Health Care Services provides care and services according to Physician or allowed Practitioner Orders and according to applicable laws and regulations. The Policy indicated Home Health Care Services staff providing care to those served (nursing) are responsible for the presence of current and continuing Physician or allowed Practitioner Orders. The Home Health Care Services Policy titled Home Health Certification and Plan of Care, undated, indicated Nursing staff are responsible for the development, implementation, evaluation and revision of the plan of care. The Home Health Care Services Policy titled Job Description – Community Health Nurse- Registered Nurse (RN), undated, indicated a RN providing professional leadership in the delivery of Nursing services necessary to support, implement the home care program in assigned area, based on client need. The Policy indicated essential responsibilities and functions of a Registered Nurse includes the following; provides direct Nursing care according to Home Health Care Services Policies and Procedures, adhere to standards of Nursing practice as set forth by the State Nurse Practice Act, implements the established Plan of Care under the direction of the Primary Care the person served, remains awake and alert at all times, and ensure that care provided is safe for the person served and their Caregivers. Review of Client #1’s Medical Record, indicated Client #1 was admitted to the Home Health Care Services in June 2006 and his/her medical diagnoses included Larsen Syndrome (a rare genetic condition affecting bone and joint development, causing multiple dislocations at birth, plus issues like clubfeet, spinal problems, short stature, facial differences and sometimes hearing loss), Respiratory Failure (a condition where lungs fail to perform gas exchange, leading to low blood oxygen or high blood carbon dioxide), Dependence on Ventilator ( a person relies on a mechanical ventilator to breathe because their own respiratory muscles or lungs can’t function adequately), Gastrostomy (a procedure to create a direct opening from the outside of the abdomen into the stomach, using a tube (G-tube) to deliver nutrition, liquids, and medications), Congenital Limb Anomaly (a baby is born with arms, legs, fingers, or toes that are missing, not fully formed, or shaped differently, resulting from issues during fetal development in the womb) and Quadriplegia (paralysis affecting all four limbs (arms and legs) and the torso, resulting from damage to the cervical (neck) spinal cord or brain, causing loss of movement and sensation below the injury level, impacting daily life significantly and sometimes requiring breathing support). Review of Client #1’s Home Health Certification, Treatment Plan and Medical Update Certification Period August 2025 to October 2025, indicated Client #1 is non-verbal, has global development delays and is not capable of either directing or participating in his/her own care. The Medical Update indicated Client #1 is unable to participate in his/her care secondary to being a Quadriplegia and is totally dependent on all his/her Activities of Daily Living (are fundamental self-care tasks essential for independent living, including bathing, dressing, toileting, transferring (moving), continence, and feeding). The Home Health Care Services Incident and Accident Report, dated 09/21/25, indicated on 09/21/25, Nurse #2 informed Clinical Manager #2 that Nurse #1, who had provided Nursing Services to Client #1 from 10:00 P.M. on 09/20/25 until 7:00 A.M. into 09/21/25, had neglected Client #1, handled Client #1’s tracheostomy harshly, did not reposition Client #1 regularly, did not unwrap Client #1’s mechanical ventilator tube when it was wrapped around Client #1’s neck, Nurse #1 did not follow Client #1’s indwelling catheter Physician Orders including not using best practice during direct care and Nurse #1 slept during her shift, all of which was based on the review of video surveillance camera footage installed in the Client #1’s bedroom. During telephone interview on 12/17/25 at 7:22 P.M., Nurse #2 said she arrived at work, on 09/21/25, at 7:00 A.M., and after Nurse #1 had left, Client #1’s Primary Caregiver approached her distraught and alleged that Nurse #1 had abused and neglected Client #1. Nurse #2 said Client #1’s Primary Caregiver showed her footage (dated 09/21/25) from a video surveillance camera that had been installed in the client’s bedroom. Review of Client #1’s Physician Orders related to the provision of Skilled Nursing Services included, but was not limited to the following: A. Assess and maintain #6.0 70 millimeters (mm) cuffed Bivona tracheostomy, continuously -Assess for suctioning requirements (tracheostomy), continuously -Nursing to Monitor ventilation and settings: -Mode: VC/SIMV/PSV.TV:275, rate: 14 -PSV:15over, PEEP 5 (20/5) -itime 1.2, PEEP:5, rise 4 -FT35, TT 1.2, sensitivity 3 -Maintain ventilator humidifier at 34-37, continuously -Assess Pulse Oximeter and documentation, continuously at night and as needed during the day -Assess Deflate tracheostomy cuff, every 2 hours during the day and evening -Nursing to check residuals (to ensure air is left in the lungs to prevent lungs from collapsing), every 2-3 hours -Assess Skilled Pulmonary Assessment including breath sounds, every 4 hours However, review of the 09/21/25 surveillance camera footage indicated Nurse #1 did the following: -03:50:57 – Nurse #1 is sitting in a chair with another chair located directly in front of her and her legs are stretched out on that chair. Nurse #1’s head is leaning towards the right side of her body against her right hand, her arm is in a bent position, elbow located on the chair arm, Nurse #1 has a blanket covering her body and she is sleeping. Based on the video and interviews it was determined that Nurse #1 had been sleeping on and off for several hours and did not perform Nursing Services for Client #1, Nurse #1 is only seen attending to Client #1 when the surveillance camera turns on after censing movement (by Nurse #1) in the room. B. Nursing to maintain Aspiration Precautions, continuously -Position Client #1’s so his/her airway is in a neutral position, continuously -Maintain Passive Range of Motion, every 4 hours as needed while awake -Do Not Range (limited extent of movement) Neck (no excessive strain on cervical spine) However, per 09/21/25 surveillance camera footage Nurse #1 did the following, which was not consistent with Client #1’s orders. -06:43:08 – Nurse #1 is on the right side of Client #1’s bed and grabs Client #1’s head from a laying position to sit Client #1 in an upward semi- sitting position. Nurse #1 is holding Client #1’s head between her armpit and forearm as she is working on Client #1’s tracheostomy collar/ties, Client #1’s head is bent forward, and Nurse #1 quickly places Client #1’s head on his/her pillow. Nurse #1 then places tracheostomy ties to the left side, the right side and then proceeds to position both of her hands around the Client #1’s neck to pull on and sit him/her up in an upward semi-position, Client #1’s head is bent in a forward position and against Nurse #1’s chest as she is working on Client #1’s tracheostomy collar/ties and then she quickly places Client #1 head on his/her pillow. Client #1’s head of the bed continues to be in a flat position. -06:48:11 – Client #1 is in bed, continues to be on his/her back, blanket covering him/her, head of bed positioned in an upward position to around 80-90 degrees. Nurse #1 is standing on the right side of the bed. Nurse #1 places her right hand on Client 1’s trachea, her left hand is located near right side of his/her neck, she adjusts Client #1’s collar/ties with a quick motion and then Nurse #1 takes her hands, grabs the back of Client #1’s head and quickly pulls his/her head in a forward position, causing his/her chin to touch his/her chest. Nurse #1’s arms rest on Client #1’s head, while she is quickly moving Client #1’s hair in an upward position to be able to see his/her neck. Nurse #1 then let’s go of Client #1’s head, Client #1’s head plops (was not lowered gently) to his/her pillow. -06:48:28 - Nurse #1 takes her right hand, places it on Client #1’s chin and pushes Client #1’s chin inward, causing his/her pillow to be depressed inward, Nurse #1 pulls Client #1’s blanket down a little with her right hand, uses her left hand positioned to the right of Client #1’s tracheostomy collar pulling towards her (Nurse #1) in a back and forth motion (twice), causing Client #1’s head to jerk to the right, forward and back. -06:49:41 – Nurse #1 puts her right hand directly on Client #1’s tracheostomy and pushes it inward, while Client #1’s head/neck is being pressed against his/her pillow, Nurse #1 then let’s go of Client #1’s tracheostomy, continues to work on his/her tracheostomy tubing and Nurse #1 then proceeds to grab the television remote. Based on the video and interviews, it was determined that Nurse #1, at multiple times throughout the night did not maintain Aspiration Precautions, did not position Client #1’s airway in a neutral position, and did not comply with the order Not to Range (required very limited extent of movement) Client #1’s neck as per Physician Orders. Review of Client #1’s Physician Orders include the following: C. Nursing to Straight Catheterization for urine to prevent autonomic dysreflexia, Every 3 hours However, per 09/21/25 surveillance camera footage Nurse #1 did the following: -It is important to note, in the video Nurse #1 (per Nurse #2’s interview as this part of the video was not provided to the Surveyors) was seen sleeping, around for several hours that night, and around midnight (per Nurse #2 who reviewed the video) Nurse #1 positioned Client #1 onto his/her side, Nurse #1 inserted a catheter (a thin, hollow, flexible tube used for short term, intermittent for bladder drainage) into Client #1, place the catheter’s distal end in a bottle (to collect Client #1’s urine) and placed a weighted bag on the bottle to maintain the position of the bottle. Nurse #1 then slept until around 5:00 A.M., which then she awakes to perform Client #1’s A.M. care. -06:13:36 – Client #1 is in bed, positioned lying on his/her right side, left leg crossed over right leg, right leg is in a bent position. -Nurse #1 is seen watching television while providing hygiene care to Resident #1. Prior to Nurse #1 pulling his/her incontinence brief out from under Client #1, Nurse #1 is seen moving her arm in an outward position away from her body and then proceeds to wrap tubing in Client #1’s incontinence brief. Nurse #1 walks away from Client #1. Nurse #2 said based on what she saw in the video, Nurse #1 did not consistently monitor or provide skilled nursing care to Client #1 in per physician’s orders, during the first part of her (Nurse #1’s) shift on the night of 9/20/25 into 9/21/25, because (on the video) she (Nurse #1) could be seen sleeping for several hours. Nurse #2 said Client #1 was susceptible to infections, and having a catheter inserted into him/her, unattended, increased Client #1 risk for infection. Nurse #2 said Client #1’s ventilation tubing always needs to stay midline (centered, line down middle of body) to allow the humidification to drain downward instead into Client #1’s trachea which can cause aspiration pneumonia. Nurse #2 said in the video Client #1’s ventilation tubing was seen above his/her neck and the head of Client #1’s bed was in a flat position, which were contraindicated. Nurse #2 said in the video Nurse #1 can be seen being rough with Client #1, including not utilizing log rolling techniques (upper and lower body moves together in one motion) with Client #1 during bed mobility. Nurse #2 said it is important to log roll him/her because Client #1 has a diagnosis of quadriplegia and Larsen Syndrome, which makes him/her more prone to easily dislocate joints and care needs to be provided gently to him/her. Nurse #2 said, Client #1 was close to the edge of his/her bed during care, which was a safety concern. During interview on 12/16/25 at 11:00 A.M., Chief Executive Officer said Client #1 has a spinal fusion and does not have head control. The Chief Executive Officer said Client #1’s Physician Orders are not to range (move-manipulate) his/her neck. Nurse #1 did not support Client #1’s head, while moving it in a forward position and laying Client #1’s head of the bed in a flat position. The Chief Executive Officer said based on review of the video Nurse #1 slept for five hours, watched television while providing care to Client #1 and did not monitor, assess or follow Client #1’s Plan of care, including continuous ventilation/tracheostomy care, Client #1’s saturation monitor was off, and Nurse #1 did not follow Client #1’s aspiration precautions. The Chief Executive Officer said in the video Nurse #1 had poor handwashing practices, had not put gloves on, was seen touching everything with his/her hands then providing direct care to Client #1. The Chief Executive Officer said Nurse #1 was rough with Client #1, not gentle with care and did not follow Agencies Policies and Procedures.”