Category 3 neglect found: failure to supervise Service Recipients. Staff did not know their whereabouts. Could have performed Subject's duties without breach.

Category 3 neglect substantiated for failure to follow facility policies on supervision.

Category 3 neglect: failure to supervise unsubstantiated. No evidence of injury/likely injury from Subject disclosing information to Service Recipient.

Category 3 neglect substantiated for failure to follow facility procedures and notify nursing.

Category 3 neglect found: failure to properly supervise PICA diagnosed Service Recipient who tried to put puzzle pieces in her mouth.

Category 3 neglect found: Subject did not intervene or call for assistance during Service Recipient's self-injurious behavior. Allegations Subject laughed/made inappropriate comments unsubstantiated.

Category 3 neglect affirmed. Subject caused serious impairment of mental or emotional condition of Service Recipient with inappropriate language.
 

Category 3 neglect found when Subject breached duty: improperly secured shower chair seat belt causing Service Recipient to fall and fracture hip.

Category 3 neglect and psychological abuse found. Subject found to have commented on Service Recipient’s sexuality in his presence.

Category 3 neglect not found. Inadequate medical care by Subject of Service Recipient who experienced multiple seizures over 10 months not proved.