Every finding on record at Maxim Healthcare Services, Inc

The following reflects the findings of the California Department of Public Health during the investigation of two complaints. Complaint Intake Numbers: 2966919 and 2978103. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was identified for Complaint Intake Number 29669191. No deficiency was identified for Complaint Intake Number 2978103.

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 interview and record review, the agency failed to ensure for one of two patients reviewed (Patient 1) was free from abuse when the Licensed Vocational Nurse (LVN) repositioned Patient 1 using rapid jerking motions; lifted her upper body while flipping pillows and abruptly released her onto the pillow without gently supporting the head and torso causing Patient 1 to bounce in the bed; covered Patient 1’s face with CPT (Chest Physical Therapy – a medical device that vibrates the chest to loosen and thin mucus in the lungs) vest; covered her face with a blanket; and told her to “keep quiet,” when she was crying. This failure had the potential for Patient 1 to suffer physical and emotional injury. Findings: Patient 1’s record was reviewed. Patient 1 was admitted to the agency on February 9, 2026, with diagnoses which included cerebral palsy (a neurological disorder that permanently affects a person’s ability to move, maintain balance and control posture). The agency’s investigation report indicated Patient 1’s mother provided in-home video footage. On May 7, 2026, at 2:25 p.m., the in-home video footage was viewed with the agency’s administrator (ADM). The footage showed the LVN did the following: - repositioned Patient 1 using rapid jerking motions; - lifted Patient 1’s head and upper body while flipping pillows and abruptly released her without gently supporting the head and upper body causing Patient 1 to bounce; - covered Patient 1’s face with the CPT vest; - covered Patient 1’s face with the sheet/blanket while changing her; and - told Patient 1 to “keep quiet,” when she was crying. In a concurrent interview with the ADM, he stated the agency’s investigation was still pending. He stated the agency was waiting for the LVN to respond to their request to come to the office and explain her actions as seen in the footage. He stated the agency attempted several times to try to contact the LVN by calling, texting and sending an email. He stated the LVN responded once and informed him that she was trying to process and deal with the incident. On May 7, 2026, at 4:18 p.m., a telephone interview was conducted with Patient 1’s primary care giver (PCG). She stated Patient 1 was her daughter and she was disabled and could not speak. She stated the LVN took care of Patient 1 for two years and noticed that Patient 1 had a change in her behavior. She stated Patient 1 did not giggle and laugh like she used to. She stated the change was gradual. She stated she decided to review video camera footage when she noticed Patient 1’s behavior was off (Patient 1 cried more and was restless) on the days that the LVN was working. She stated as soon as she saw the video footage, she called the agency and reported the LVN. She stated the agency replaced the LVN with a different LVN. She stated Patient 1 was better, she was smiling and giggling again. On May 8, 2026, at 11:30 a.m., a telephone interview was conducted with the Clinical manager (CM). She stated the LVN had been on administrative leave since the agency received the complaint from Patient 1’s PCG. She stated the LVN did not respond to the agency’s request to call them. On May 27, 2026, at 11:59 a.m., a telephone interview was conducted with the LVN. She stated she was surprised with the allegations that Patient 1’s PCG reported to the agency. She stated the CM informed her of the allegations. She stated the CM showed her some video footage and there was nothing in the footage that she abused Patient 1. The LVN was informed that the surveyor saw the footage, and she was seen placing the CPT vest on Patient 1’s face. She stated she could not recall that incident. The LVN was also informed that she was seen in the video footage that she placed a blanket on Patient 1’s face while changing her. She stated she did that to minimize the stimulation that Patient 1 was receiving during care. She stated she would see Patient 1’s eyes covered with a blanket when she came every morning for her shift. She stated the PCG told her that it would make Patient 1 calm and comfortable. The LVN was informed that she was seen in the video lifting Patient 1’s head and upper body while flipping pillows and abruptly released her without gently supporting the head and upper body causing Patient 1 to bounce and when she turned the Patient 1 from side to side she turned her so fast. LVN stated she acknowledged those actions and she was in a hurry so Patient 1 could feel relaxed sooner and not feel all the activities but not cause harm. She stated if she could go back and do it again, she would have done it differently and gently. The agency’s policy and procedure titled, “ABUSE, NEGLECT, OR EXPLOITATION, “revised January 30, 2026, indicated, “The Company will promote an abuse-, neglect, and exploitation-free environment for all patients/clients receiving care, treatment and/or services.

The following reflects the findings of California Department of Public Health during an investigation of one complaint and one Facility Reported Incident. Complaint number: 2962480. Facility Reported Incident number: 2743316. The inspection was limited to the specific complaint and Facility Reported Incident investigated and does not represent the findings of a full inspection of the agency. Three deficiencies were issued for complaint number 2962480 and Facility Reported Incident number 2743316.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the Licensed Vocational Nurse (LVN) notified the physician for one of three patients reviewed (Patient A), when Patient A’s GJ tube (gastrojejunostomy tube – a soft, narrow tube, that goes through the skin and muscle into the stomach and then into the small intestine [jejunum]) was accidentally dislodged. This failure resulted in Patient A’s delay in treatment. Findings: On May 25, 2025, Patient A’s record was reviewed. Patient A was admitted to the agency with start of care (SOC) date of May 30, 2023, with diagnoses which included cerebral palsy (a group of permanent neurological disorders affecting muscle movement, muscle tone, and posture due to abnormal brain development or damage, usually before or around birth). Patient A’s Plan of Care (POC) for the certification period of January 14, 2026, to March 14, 2026, indicated the following: - “…Enteral (medical administration of nutrients or medication directly into the gastrointestinal tract typically via the stomach or small intestine) Tube Type/Size…GJ Tube (brand name) mini; and - Notify MD (physician) and clinical supervisor for dislodgement/malfunction/occlusion…” The Skilled Nursing notes dated February 3, 2026, indicated that the GJ tube accidentally came out and was reported to Patient A’s primary care giver (PCG – parents). There was no documented evidence that the LVN notified Patient A’s physician that the GJ tube accidentally came out. The Skilled Nursing notes dated February 11, 2026, indicated Patient A had to be taken by her family for an x-ray of the GJ tube to determine if she had to go to the ER (emergency room). Patient A’s mother indicated Patient A was retching (mimicking vomiting without ejecting stomach contents), did not tolerate the feeding and was given Pedialyte (an electrolyte drink for fast, effective rehydration in children and adults). The Skilled Nursing notes dated February 13, 2026, indicated Patient A was diagnosed with aspiration pneumonia (a serious lung infection caused by inhaling food, liquid, saliva, or vomit into the airways) and was on antibiotics (medications that treat infections). On March 25, 2026, at 1:13 p.m., during an interview with the Administrator (ADM), she stated the LVN did not notify the physician and/or the agency when Patient A’s GJ-tube was dislodged. The ADM stated the LVN should have notified the physician and called the agency. On March 25, 2026, at 2:25 p.m., a telephone interview was conducted with the LVN. She stated that on February 3, 2026, at 3 p.m., she observed Patient A’s GJ-tube was accidentally dislodged. The LVN stated she notified Patient A’s parents but did not notify the physician. She stated she did not follow the POC to notify the physician and clinical supervisor when the GJ-tube was dislodged. On March 25, 2026, at 3:03 p.m., the Clinical Supervisor (CS) was interviewed. She stated Patient A did not have an order to re-insert the GJ-tube when dislodged. She stated the standard of practice was for the licensed nurse to assess the patient and notify the physician and the CS when there was a change in the patient’s condition. The agency’s policy and procedure titled, “ONGOING EVALUATION,” revised July 1, 2022, indicated, “…Direct Care Staff…Those individuals that provide or (sic) direct care to the patient in his/her home or alternate care setting…The Direct Care Staff shall notify the office clinical leader or clinical designee and/or ordering practitioner when there is a change in the patient condition…”

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to provide competent and safe skilled services for one of three patients reviewed (Patient A) when the Licensed Vocational Nurse (LVN) attempted to re-insert a GJ tube (gastrojejunostomy tube – a soft, narrow tube, that goes through the skin and muscle into the stomach and then into the small intestine [jejunum]) that was accidentally dislodged. This failure had the potential for Patient A to experience complications (bleeding, severe infection, obstruction, pain). Findings: Patient A’s record was reviewed. Patient A was admitted to the agency with start of care (SOC) date of May 30, 2023, with diagnoses which included cerebral palsy (a group of permanent neurological disorders affecting muscle movement, muscle tone, and posture due to abnormal brain development or damage, usually before or around birth). Patient A’s Plan of Care (POC) for the certification period of January 14, 2026, to March 14, 2026, indicated the following: - “…Enteral (medical administration of nutrients or medication directly into the gastrointestinal tract typically via the stomach or small intestine) Tube Type/Size…GJ Tube (brand name) mini; and - NOT to be changed in home…” The Skilled Nursing notes dated February 3, 2026, indicated that the GJ tube accidentally came out and was reported to Patient A’s primary care giver (PCG – parents). The Skilled Nursing notes dated February 11, 2026, indicated Patient A had to be taken by her family for an x-ray of the GJ tube to determine if she had to go to ER (emergency room). Patient A’s mother indicated Patient A was retching (mimicking vomiting without ejecting stomach contents), did not tolerate the feeding and was given Pedialyte (an electrolyte drink for fast, effective rehydration in children and adults). The Skilled Nursing notes dated February 13, 2026, indicated Patient A was diagnosed with aspiration pneumonia (a serious lung infection caused by inhaling food, liquid, saliva, or vomit into the airways) and was on antibiotics (medications that treat infections). On March 25, 2026, at 1:13 p.m., during an interview with the Administrator (ADM), she stated she was not sure why the LVN attempted to re-insert the GJ tube when there was no order to re-insert the GJ tube when dislodged. The ADM showed the surveyor a MIC-KEY button (brand name) GJ tube and stated it was a special type of feeding tube and there was an order not to insert the GJ tube at home. She stated when she asked the LVN if she knew about the POC for Patient A, the LVN told her she was not aware of the specific order for the GJ tube. The ADM stated there was a copy of Patient A’s POC at home. On March 25, 2026, at 2:25 p.m., a telephone interview was conducted with the LVN. She stated that on February 3, 2026, at 3 p.m., she observed Patient A’s GJ-tube was accidentally dislodged. She stated she attempted to re-insert the GJ-tube but was unsuccessful. The LVN stated she thought she needed to reinsert the tube back to prevent the stoma (a surgically created hole) from closing. She stated the GJ tube was completely out with the balloon (part of the GJ tube that secures the device inside the stomach, preventing it from dislodging) inflated. She stated she did not deflate the balloon when she attempted to re-insert the GJ-tube. The LVN stated she should not have attempted to re-insert Patient A’s GJ-tube. On March 25, 2026, at 3:03 p.m., during an interview with the Clinical Supervisor (CS), she stated in order to evaluate the competency of the staff, an in-home evaluation or competency should be conducted. The staff should be able to demonstrate and verbalize the procedure for the task. She stated she would not know if the LVN had an actual demonstration of a G-tube (gastrostomy tube – a type of enteral tube) or a GJ-tube care in-home competency evaluation since she was not the CS who conducted the evaluation. The agency’s policy and procedure titled, “COMPETENCY ASSESSMENT – DIRECT CARE STAFF,” revised October 10, 2025, indicated, “…An employee may not be deemed competent in a particular task or skill if all elements of a return demonstration, and successful completion of managing competency scenarios was not observed by the evaluator…Competence…The ability of an individual to do a job properly…Competency. An evaluation of the knowledge and critical thinking skills of a clinician…”

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 interview and record review, the facility failed to ensure the Plan of Care (POC) was followed for one of three patients reviewed (Patient A) when the Licensed Vocational Nurse attempted to re-insert a GJ tube (gastrojejunostomy tube – a soft, narrow tube that goes through the skin and muscle into the stomach and then into the small intestine [jejunum]) that was accidentally dislodged. This failure had the potential for Patient A to develop complications that could lead to serious health problems. Findings: On May 25, 2025, Patient A’s record was reviewed. Patient A was admitted to the agency with start of care (SOC) date of May 30, 2023, with diagnoses which included cerebral palsy (a group of permanent neurological disorders affecting muscle movement, muscle tone, and posture due to abnormal brain development or damage, usually before or around birth). Patient A’s Plan of Care (POC) for the certification period of January 14, 2026, to March 14, 2026, indicated the following: - “…Enteral (medical administration of nutrients or medication directly into the gastrointestinal tract typically via the stomach or small intestine) Tube Type/Size…GJ Tube (brand name) mini; - NOT to be changed in home; - Must be inserted/re-inserted by MD (medical doctor);and - Notify MD (physician) and clinical supervisor for dislodgement/malfunction/occlusion…” The Skilled Nursing notes dated February 3, 2026, indicated that the GJ tube accidentally came out and was reported to Patient A’s primary care giver (PCG – parents). There was no documented evidence that the LVN notified Patient A’s physician that the GJ tube accidentally came out. On March 25, 2026, at 1:13 p.m., during an interview with the Administrator (ADM), she stated she was not sure why the LVN attempted to re-insert the GJ tube when there was no order to re-insert the GJ tube when dislodged. She stated the LVN did not follow the physician’s order, which was in the POC. She stated when she asked the LVN if she knew about the POC for Patient A, the LVN stated she was not aware of the specific order for the GJ tube. The ADM stated there was a copy of Patient A’s POC at home. On March 25, 2026, at 2:25 p.m., a telephone interview was conducted with the LVN. She stated that on February 3, 2026, at 3 p.m., she observed Patient A’s GJ-tube was accidentally dislodged. She stated she attempted to re-insert the GJ-tube but was unsuccessful. She stated she thought the stoma (a surgically created opening on the abdomen) would close so she attempted to reinsert it. The LVN stated she did not follow Patient A’s POC. The agency’s policy and procedure titled, “HOME HEALTH CERTIFICATION AND PLAN(S) OF CARE,” revised January 17, 2025, indicated, “…To provide direct care staff with ordering practitioner’s ordered treatments, procedures, medications, and services to meet the patient’s home care needs…The Home Health Certification Plan of care (485) is the ordering practitioner’s order for home care services…The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff(s)…”