Every finding on record at Maxim Healthcare Services, Inc

The following reflects the findings of California Department of Public Health during a complaint validation survey authorized by Centers for Medicare and Medicaid Services (CMS) for intake numbers 2636265, 2637115, and 2640526. The inspection was limited to the specific Conditions of Participation investigated and does not represent the findings of a full inspection of the agency. The following Conditions of Participation were surveyed: CFR 484.50 Patient Rights; CFR 484.60 Care Planning, Coordination, Quality of Care; and CFR 484.75 Skilled Professional Services. One standard level deficiency was issued.

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 observation, interview, and record review, the agency failed to provide a safe environment for one (Patient A) of two patients reviewed when Patient A who sustained second degree burns (burn occurs on the first layer and some of the second layer of the skin) when the Licensed Vocational Nurse (LVN) soaked Patient A’s feet in lukewarm water on October 2, 2025. The LVN was allowed to work with Patient A on October 4, 5, and 19, 2025, while there was an on-going investigation of the incident. This failure had the potential to cause an unsafe environment for Patient A. Findings: A review of Patient A’s record on November 19, 2025, indicated Patient A was admitted to the agency on December 13, 2019, with diagnoses which included chronic respiratory failure (a long-term condition where the lungs cannot supply enough oxygen to the body) The plan of care (POC) for the certification period from September 12, 2025, to November 10, 2025, was reviewed. The Registered Nurse (RN) “CARE SUMMARY, “at the start of care (SOC) on September 12, 2025, indicated, “…male, completely disabled and dependent for all care. He is unresponsive, all signs of discomfort are only in change of vital signs…” The agency’s document titled, “Orders for Discipline and Treatments,” dated September 12, 2025, indicated, “PERSONAL CARE: Provide personal care as needed to include bathing, dressing, diapering, skin and oral care. Report alteration in skin integrity unresolved by interventions as prescribed by physician…” The Skilled Nursing (SN) notes dated October 2, 2025, at 4:18 p.m., indicated the LVN soaked Patient A’s feet in warm water with soap. The SN notes also indicated that after soaking Patient A’s feet in soap and water, Patient A’s skin began “sloughing (shed off).” Patient A’s feet were red with scant (small amount) serous (serum – clear liquid part of the blood) drainage. The SN notes dated October 2, 2025, at 8:14 p.m., indicated Patient A’s both feet were red, swollen, with a small opening on the bottom of the right foot and the left small toe with blood. The SN notes also indicated portions of skin peeling off. Patient A was sent to the hospital for evaluation. A review of Patient A’s record from the general acute care hospital (GACH), provided by Patient A’s primary caregiver (PCG), dated October 2, 2025, indicated Patient A had a second-degree burn. On November 20, 2025, at 1:20 p.m., during a home visit with Patient A, Patient A was observed lying in bed attached to a ventilator (a life-support machine that moves air in and out of a patient’s lungs, used when a person cannot breathe on their own due to a medical condition or surgery). Patient A’s bilateral feet were wrapped with Kerlix roll (a type of wound dressing). On November 20, 2025, at 1:30 p.m., Patient A’s primary caregiver (PCG) was interviewed. She stated the LVN took care of Patient A on October 2, 2025. She stated the LVN called her in Patient A’s room. She stated the LVN soaked Patient A’s feet in soapy warm water. She stated Patient A’s feet were red and skin peeled off. The PCG stated Patient A was transferred to the hospital. She stated Patient A returned from the hospital with second-degree burns to his feet. She stated the LVN came back after the incident and took care of Patient A for a couple of days. A review of the LVN’s schedule indicated the LVN worked with Patient A on October 4, 5, and 19, 2025. On November 21, 2025, at 12:40 p.m., the Administrator (ADM) and the Assistant Administrator/Director of Operations (AADM/DO) were interviewed. The ADM stated Patient A’s second-degree burns to both feet was considered a change of condition and the LVN did not act maliciously. The ADM stated she initiated an investigation on October 6, 2025. She stated the LVN was not removed from the schedule immediately. The ADM did not respond when asked why the LVN was not removed from the schedule for Patient A. The AADM/DO acknowledged that the LVN should have been removed from patient assignment since there was an on-going investigation even if the incident was not an abuse allegation. He stated that since there was harm to the patient, it was the agency’s responsibility to protect the patient. A review of the agency’s document titled, “INCIDENT REPORTS,” revised October 6, 2025, indicated, “…The Incident Reporting System is a component of the Quality Improvement program which is designed to identify all actual or potential occurrences that could have an impact on the patient/client or the patient/client’s family/caregiver…DEFINITIONS…Incident: Any situation involving a patient/client or family member/caregiver which is not consistent with regular routine, regardless of whether or not there was an apparent injury or other damage…Improving the management of care, treatment and services by assuring that appropriate and immediate interventions occurs for the patient/client’s safety and to assure the prevention of occurrences…”

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted on November 1, 2021 to November 2, 2021. Representing the California Department of public Health: Surveyor 29623, HFEN. The following Conditions of Participation were reviewed: Patient Rights; and Organization and Administration of Services. The agency's census was 74 patients. The sample size was 3 patients. The home visits conducted were for 2 patients.

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 observation, interview, and record review, the agency failed to remove Licensed Vocational Nurse (LVN) 1 immediately from patient care for one of three sampled patients (Patient 1), when there was allegation of misconduct related to abuse. This failure resulted in LVN 1 to continue caring for Patient 1 for 15 days and putting Patient 1 at risk for potential harm. Findings: On November 1, 2021, Patient 1's record was reviewed. Patient 1 was admitted to the agency on April 15, 2010, with diagnoses which included tuberous sclerosis (a rare multi-system genetic disease that causes non-cancerous tumors) and convulsions (uncontrollable muscle contractions). The Plan Of Care (POC) for the certification period from October 14, 2021 to December 12, 2021, was reviewed. The POC indicated the following: - "...Skilled Nurse (SN) to attend any outings from home during shift with the patient; -...Skilled nursing to perform skilled monitoring and observation each shift and as needed for any changes in patient condition. Report all adverse changes to the physician/Registered Nurse (RN)/Caregiver; and -...Born with tubular sclerosis. Developmentally delayed with significant seizure disorder. Had cranial (brain) surgery on February 2011 which removed all left brain except small portion of frontal lobe (located directly behind the forehead). Very physically active with no sense of safety for either herself nor others...maximum/moderate assistance for all other Activity of Daily Living (ADL). Ambulatory but must have hands on 100% when out of home..." The agency's document titled, "Nursing Flow Sheet," dated September 24, 2021, was reviewed. The document indicated the following: - Patient 1 was non-verbal, alert; - Weight: 250 pounds, Height: 5 feet; - Incontinent of urine; - Full Range of Motion; - "...11:30 a.m., pt (patient) out of house ready to go for drive around town; and - ...14:30 pt irritable, I got off freeway...hitting anything...at arms length. I evacuated car and gave her time to relax. a worried observer came to assist me..." The document from Murrieta Police Department dated September 24, 2021, at 14:39 p.m., was reviewed. The report indicated the following: - The reporting party (RP) called the police for allegation of abuse towards Patient 1 by LVN 1; - The responding police officer observed there was no visible injuries to Patient 1, and determined that no crime had occurred; - LVN 1's statement explained Patient 1 woke up late for school, so she decided to take Patient 1 for a drive to get her out of the house; - On the way back home, Patient 1 got agitated and unbuckled her seat belt. Patient 1 was at the backseat of LVN 1's vehicle; - Patient 1 began kicking LVN 1's head as she was driving; - Fearing for her safety as well as the safety of others on the road, LVN 1 decided to pull over; - LVN 1 opened the rear passenger door to where Patient 1 was sitting, waited for her to calm down so she could put Patient 1's seat belt back on; - LVN 1 reached in to put Patient 1's seat belt on, when Patient 1 grabbed and started pulling on LVN 1's hair; - LVN 1 being unable to free herself, she reacted by punching Patient 1 in the stomach...LVN 1 said she did not put full force behind the punches and Patient 1 let her hair go; and - LVN 1 told the officer her intent was not to harm Patient 1 and she should have made a better decision instead of making physical with Patient 1. LVN 1's work schedule from September 24, 2021 to October 19, 2021, was reviewed. The work schedule indicated LVN 1 cared for Patient 1 on the following dates: - September 24, 2021, from 7:57 a.m. to 8 p.m.; - September 28, 2021, from 7:04 a.m. to 3 p.m.; - September 29, 2021, from 7:01 a.m. to 3:07 p.m.; - September 30, 2021, from 7:03 a.m., to 3:02 p.m.; - October 1, 2021, from 8 a.m. to 11:15 a.m., and from 2:30 p.m. to 8 p.m.; - October 4, 2021, from 7:11 a.m., to 10:15 a.m., and from 2:35 p.m., to 3 p.m.; - October 5, 2021, from 7:04 a.m. to 2:58 p.m.; - October 6, 2021, from 7:04 a.m., to 10:54 a.m., and from 2;37 a.m. to 3:08 p.m.; - October 8, 2021, from 8:27 a.m. to 2 p.m.; - October 11, 2021, from 7 a.m. to 11;01 a.m., and from 2:36 p.m. to 3 p.m.; - October 12, 2021, from 7:02 a.m. to 11 a.m., and from 2:36 p.m. to 3 p.m.; - October 13, 2021, from 7:22 a.m. to 11:33 a.m., and from 2:30 p.m. to 3:08 p.m.; - October 14, 2021, from 7 a.m. to 12:55 p.m.; - October 15, 2021, from 7 a.m. to 10:15 a.m., and from 2:32 p.m. to 8 p.m.; - October 18, 2021, from 7:58 a.m. to 8:42 a.m., and from 2:28 p.m. to 3:03 p.m.; and - October 19, 2021, from 6:56 a.m. to 2:49 p.m. The agency's document titled, "Corrective Action Form," dated October 19, 2021, was reviewed. The document indicated LVN 1 was placed on Administrative Leave on October 19, 2021, at 4:21 p.m. On November 1, 2021, at 3:31 p.m., a home visit was conducted with Licensed Vocational Nurse (LVN) 2, for Patient 1. Patient 1's Primary Care Giver (PCG) was at home during the visit. Patient 1 was observed asleep in her bedroom. A concurrent interview was conducted with Patient 1's PCG. The PCG stated Patient 1 had episodes of uncontrolled seizures and had developed post ictal rage (severe burst of rage and aggression after seizure). The PCG stated she was recovering from broken wrist as a result of Patient 1's post ictal aggression. She stated she found out about the incident on September 24, 2021, when LVN 1 returned home with Patient 1. She stated she contacted the police officer immediately and she was told LVN 1 acted in self defense when Patient 1 became violent as LVN 1 was driving. She stated LVN 1 had cared for Patient 1 for two years and she did not believe LVN 1's action was intended to harm Patient 1. At 5:15 p.m., Patient 1 was observed awake and was assisted by LVN 2 to the dining table. Patient 1 was non verbal, able to make sounds and gestures to LVN 2. Patient 1 was observed eating finger food snacks while watching television. A concurrent interview was conducted with Patient 1's PCG. The PCG stated Patient 1 was being home-schooled. The PCG stated she was told by the agency that licensed staff was not allowed to drive Patient 1 out of the house after the incident. On November 2, 2021, at 2:30 p.m., a concurrent interview and record review was conducted with the agency's Administrator. The Administrator stated LVN 1 was not taken off from her work schedule when she was told by LVN 1 that the policer officer informed LVN 1, "no crime" was committed at the scene of the incident on September 24, 2021. The Administrator confirmed LVN 1 continued to care for Patient 1 from September 20, 2021 through October 19, 2021, as indicated in her work schedule. She stated LVN 1 should have been taken off from work, since there was allegation of misconduct related to abuse. The agency's policy and procedure titled, "ABUSE, NEGLECT, OR EXPLOITATION," dated April 9, 2021, was reviewed. The policy indicated, "...The Company will promote an abuse-,neglect- and exploitation-free environment for all patient/clients receiving care, treatment and/or services,,," The agency's policy and procedure did not specifically indicate how to protect patients from staff when there was allegation of misconduct related to abuse.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to follow their corrective action policy to protect the patient while allegation of abuse was being investigated for one of three sampled patients, (Patient 1). This failure resulted in LVN 1 having to continue the care for Patient 1 and was not placed on administrative leave immediately putting Patient 1 at risk for potential harm. Findings: On November 1, 2021, Patient 1's record was reviewed. Patient 1 was admitted to the agency on April 15, 2010, with diagnoses which included tuberous sclerosis (a rare multi-system genetic disease that causes non-cancerous tumors) and convulsions (uncontrollable muscle contractions). The Plan Of Care (POC) for the certification period from October 14, 2021 to December 12, 2021, was reviewed. The POC indicated the following: - "...Skilled Nurse (SN) to attend any outings from home during shift with the patient; - ...Skilled nursing to perform skilled monitoring and observation each shift and as needed for any changes in patient condition. Report all adverse changes to the physician/Registered Nurse (RN)/Caregiver; and - ...Born with tubular sclerosis. Developmentally delayed with significant seizure disorder. Had cranial (brain) surgery on February 2011 which removed all left brain except small portion of frontal lobe (located directly behind the forehead). Very physically active with no sense of safety for either herself nor others...maximum/moderate assistance for all other Activity of Daily Living (ADL).Ambulatory but must have hands on 100% when out of home..." The agency's document titled, "Nursing Flow Sheet," dated September 24, 2021, was reviewed. The document indicated the following: - Patient 1 was non-verbal, alert; - Weight: 250 pounds, Height 5 feet; - Incontinent of urine; - Full Range of Motion; - "...11:30 a.m., pt (patient) out of house ready to go for drive around town; and - ...1430 pt irritable, I got off freeway...hitting anything...at arms length. I evacuated car and gave her time to relax. a worried observer came to assist me..." The document from Murrieta Police Department dated September 24, 2021, at 14:39 p.m., was reviewed. The report indicated the following: - The reporting party (RP) called the police for allegation of abuse towards Patient 1 by LVN 1; - The responding police officer observed there was no visible injuries to Patient 1, and determined that no crime had occurred; - LVN 1's statement explained Patient 1 woke up late for school, so she decided to take Patient 1 for a drive to get her out of the house; - On the way back home, Patient 1 got agitated and unbuckled her seat belt. Patient 1 was at the backseat of LVN 1's vehicle; - Patient 1 began kicking LVN 1's head as she was driving; - Fearing for her safety as well as the safety of others on the road, LVN 1 decided to pull over; - LVN 1 opened the rear passenger door to where Patient 1 was sitting, waited for her to calm down so she could put Patient 1's seat belt back on; - LVN 1 reached in to put Patient 1's seat belt on, when Patient 1 grabbed and started pulling on LVN 1's hair; - LVN 1 being unable to free herself, she reacted by punching Patient 1 in the stomach...LVN 1 said she did not put full force behind the punches and Patient 1 let her hair go; and - LVN 1 told the officer her intent was not to harm Patient 1 and she should have made a better decision instead of making physical with Patient 1. LVN 1's work schedule from September 24, 2021 to October 19, 2021, was reviewed. The work schedule indicated LVN 1 cared for Patient 1 on the following dates: - September 24, 2021, from 7:57 a.m. to 8 p.m.; - September 28, 2021, from 7:04 a.m. to 3 p.m.; - September 29, 2021, from 7:01 a.m. to 3:07 p.m.; - September 30, 2021, from 7:03 a.m., to 3:02 p.m.; - October 1, 2021, from 8 a.m. to 11:15 a.m., and from 2:30 p.m. to 8 p.m.; - October 4, 2021, from 7:11 a.m., to 10:15 a.m., and from 2:35 p.m., to 3 p.m.; - October 5, 2021, from 7:04 a.m. to 2:58 p.m.; - October 6, 2021, from 7:04 a.m., to 10:54 a.m., and from 2;37 a.m. to 3:08 p.m.; - October 8, 2021, from 8:27 a.m. to 2 p.m.; - October 11, 2021, from 7 a.m. to 11;01 a.m., and from 2:36 p.m. to 3 p.m.; - October 12, 2021, from 7:02 a.m. to 11 a.m., and from 2:36 p.m. to 3 p.m.; - October 13, 2021, from 7:22 a.m. to 11:33 a.m., and from 2:30 p.m. to 3:08 p.m.; - October 14, 2021, from 7 a.m. to 12:55 p.m.; - October 15, 2021, from 7 a.m. to 10:15 a.m., and from 2:32 p.m. to 8 p.m.; - October 18, 2021, from 7:58 a.m. to 8:42 a.m., and from 2:28 p.m. to 3:03 p.m.; and - October 19, 2021, from 6:56 a.m. to 2:49 p.m. The agency's document titled, "Corrective Action Form," dated October 19, 2021, was reviewed. The document indicated LVN 1 was placed on Administrative Leave on October 19, 2021, at 4:21 p.m. On November 1, 2021, at 3:31 p.m., a home visit was conducted with Licensed Vocational Nurse (LVN) 2,for Patient 1. Patient 1's Primary Care Giver (PCG) was at home during the visit. Patient 1 was observed asleep in her bedroom. A concurrent interview was conducted with Patient 1's PCG. PCG stated Patient 1 had episodes of uncontrolled seizures and had developed post ictal rage (severe burst of rage and aggression after seizure). The PCG stated she was recovering from broken wrist as a result of Patient 1's post ictal aggression. She Stated she found out about the incident on September 24, 2021, when LVN 1 returned home with Patient 1. She stated she contacted the police officer immediately and she was told LVN 1 acted in self defense when Patient 1 became violent as LVN 1 was driving. She stated LVN 1 cared for Patient 1 for two years and she did not believe LVN 1's action was intended to harm Patient 1. At 5:15 p.m., Patient 1 was observed awake and was assisted by LVN 2 to the dining table. Patient 1 was non verbal, able to make sounds and gestures to LVN 2. Patient 1 was observed eating finger food snacks while watching television. A concurrent interview was conducted with Patient 1's PCG. The PCG stated Patient 1 was being home-schooled. The PCG stated she was told by the agency that licensed staff was not allowed to drive Patient 1 out of the house after the incident. On November 2, 2021, at 2:30 p.m., a concurrent interview and record review was conducted with the agency's Administrator and the Operation Manager. The Administrator stated LVN 1 was not placed on administrative leave immediately when she was told by LVN 1 that the policer officer informed LVN 1, "no crime" was committed at the scene of the incident on September 24, 2021. The Administrator confirmed LVN 1 continued to care for Patient 1 from September 20, 2021 until October 19, 2021, as indicated in her work schedule. She stated LVN 1 should have been placed on administrative leave immediately. The Administrator and the Operation Manager stated the agency's corrective action policy was not implemented. The agency's policy and procedure titled, "Corrective Action Policy," dated November 20, 2019, was reviewed. The policy indicated, "...Should the Company receive a report of a concern including...allegations of...patient abuse...the Company has the authority to immediately place the employee on an administrative leave in order to conduct an internal investigation..."