Category 4 substantiated for systemic problems: inadequate training, failure to ensure orders implemented timely in absence of supervisory staff.

Category 4 neglect found against Provider: systemic inadequate supervision & failure to maintain adequate responsibility policies.

Category 4 Neglect found. Neglect of Service Recipient substantiated. However perpetrator of neglect could not be identified.

Category 4 neglect found for failing to provide sanitary housing conditions. Perpetrator could not be identified.

Category 4 neglect found when facility exposed Service Recipient to harm by failing to have a visitor policy or procedure.

Category 4 neglect found when facility exposed service recipients to harm through systemic problems of inadequate management, staffing, training, and supervision.