**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one (#3) out of 14 residents at risk for elopement with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. The facility failed to ensure the secured unit exit door and door alarms were operating properly, failed to check the surroundings when the exit door alarmed, and failed to account for the whereabouts of all elopement risk residents on 3/6/2024. Resident #3 exited the secured unit of the facility via a maglock alarming dining room exit door on 3/6/24 at approximately 3:45 PM and was located at approximately 5:30 p.m. 0.8 miles away. The resident would have traveled across a busy 6-lane intersection with a speed limit of 45 MPH to reach this destination. The facility staff did not recognize the resident was missing. Resident #3 was returned to the facility approximately 2 hours later by an off-duty staff member. No assessment, interventions, or supervision measures were put in place and the resident eloped from the facility a second time approximately 20 minutes later using the same alarming exit door. The resident was observed outside by a nurse on break who notified additional staff to help intervene. Resident #3 became increasingly agitated/aggressive and crossed a two-lane road in front of the facility with a speed limit of 35 MPH where he was nearly hit by a vehicle before emergency services were contacted for assistance. This neglect created a situation that resulted in the likelihood for serious injury and/or death to Resident #3 and resulted in the determination of Ongoing Immediate Jeopardy beginning on 3/6/2024. Findings Included: A review of Resident#3's hospital records revealed a History of Present Illness (HPI) dated 02/02/2024 at 4:48 AM by a Physician's Assistant (PA). Chief complaint: Altered Mental Status [AMS]. HPI narrative: [AGE] year-old male with a history of inguinal hernia, cognitive disorder/dementia, alcohol use disorder, and homelessness presents to the emergency department by PD [Police Department]. According to what I can ascertain by triage the patient was found by PD in a convenience store. Patient appeared confused and was brought to the ER [Emergency Room]. A review of the ER exam narrataive revealed the patient is disheveled and has urine soaked close [sic]. The medical decision narrative revealed the patient is alert to person and place but confused on date and time. The plan was to perform an AMS workup. On 02/02/2024 at 9:12 AM, Security voiced concern that the patient was wandering outside and did not seem to know where he was going or where he was. Registered Nurse (RN) went outside and reassessed the patient. He says he knows where he is going, but cannot tell us how to get where he is going. He keeps repeating himself. He cannot provide an address. His orientation is the same as previous. The PA reported this is chronic for this patient. The Advanced Registered Nurse Practitioner (ARNP) did not feel the patient was safe to be discharged from the hospital. He was escorted back inside. The ARNP discussed the patient with case management (CM), and the patient was admitted to work on getting patient capacity and possible long-term placement. Differential Diagnosis included AMS, dementia, Alzheimer's, and homelessness. A review of Resident #3's hospital case management notes revealed: 02/02/2024 at 9:18 AM - the patient was residing in a group home since August 2023 and now required a locked facility. 02/02/2024 at 2:01 PM resident has been accepted for transport to current skilled nursing facility. Review of Resident #3's Hospital to Nursing Home Medical Certification Transfer Form (Form 5000-3008), dated 02/02/2024, showed the resident required a surrogate for medical decision making and a primary diagnosis of AMS. The transfer form showed a patient risk alert for elopement and documented the patient was alert and disoriented but could follow simple instructions. Review of Resident #3's initial nursing evaluation collection tool, dated 02/02/2024 at 10:30 PM revealed a diagnosis of AMS, poor cognitive recall, orientation to person and place only. The resident was refusing care and had permanent medical needs with no plans to discharge from the facility anticipated. Review of a Nurse's Note dated 02/02/2024 at 11:30 PM showed Resident #3 refused to enter the facility initially and was eventually transported into the facility by wheelchair. The resident was alert and confused. Review of Resident #3's initial admission Wander Data Collection Tool, dated 02/02/2024 showed a score of 7 (3 or more Yes answers - Definite Risk for elopement.). The score of 7 was from the following Yes responses: 1. Has the resident wandered before, at home or in previous living settings? 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place? 3. Is the resident cognitively impaired with poor decision-making skills? 4. Is the resident a new admission and not accepting the new living arrangement? 5. Does the resident ambulate independently with or without an assistive device? 6. Does the resident talk about his desire to go home, talked about going on a trip, or packed up his belongings to leave? 7. Does the resident's former profession reflect the current behavior of wandering? (Documented past profession of truck driver). The sections of the wander data collection tool to list Resident #3's interventions and summary of findings was not completed for the initial admission on [DATE]. Review of Resident #3's Baseline Care Plan dated 02/02/24 at 11:30 p.m. revealed checkmarks were made for: No safety issues. Elopement risk - Intervention(s): ____________ The space to document elopement intervention(s) was blank. A review of Resident #3's Brief Interview for Mental Status (BIMS), dated 2/4/24, revealed seven of seven cognitive function indicators had a score of zero. The BIMS summary score section was blank; however, the total score of zero indicated severe cognitive impairment. The Staff Assessment for Mental Status, dated 2/4/2024 showed Resident #3 had short-term and long-term memory problems. The resident's Memory/Recall Ability revealed the resident did not know the current season, staff names and faces, or that he was in a nursing home. Resident #3 knew the location of his room. A review of Resident #3's Progress Note-MD [Medical Doctor] History & Physical dated 2/5/24, by the resident's physician (who is the facility's Medical Director) confirmed the resident's recent history of dementia, homelessness, and past alcohol use with recent admission to the nursing home after the hospital determined discharge to be unsafe without supervision. The physician described Resident #3 as pleasantly confused, oriented to self and not sure of the date, current location, or how he arrived to the facility. The resident alluded to having things to do and referred to people/situations that don't appear grounded in reality. Resident stated, I've got to go take these things somewhere, states he knows where but doesn't share the location. Resident wants to know how much longer he will be here. Per report has intermittently been kicking and sleeping under secure unit door. Assessment/Plan revealed diagnoses of dementia in other diseases classified elsewhere, unspecified severity with anxiety. Reported behavioral disturbances - intermittent anxiety/agitation and exit seeking. Begin Hydralazine 25 mg by mouth every six hours as needed (PRN) for agitation. A review of a Nurse's Note dated 2/6/23 [sic] at 10:00 AM showed Resident #3 was alert with confusion. Constantly looking for exit door to go back to Daytona. A review of the February 2024 Medication Administration Record (MAR) revealed the resident was administered Hydralazine 25 mg for anxiety on 2/6/24. This medication was not administered again, and the order was discontinued on 2/14/24. Review of a Psychiatric Evaluation and assessment for medical decision-making capacity, dated 2/8/24 by the psychiatric Advanced Registered Nurse Practitioner (ARNP), showed Resident #3 was alert, oriented to self only. The staff said resident was exit seeking upon arrival to the facility but was redirectable. The patient is not able to recognize his medical condition and the probable consequences of lack of treatment, nor the treatment options. The patient is not able to engage in a rational process of manipulating relevant information. Patient is unable to discuss the risk and benefits of his choices, and the alternative to treatment. In my opinion, this patient lacks the capacity to make decisions related to his need for health care, or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care. In addition, the patient is unable to make a rational evaluation of the burdens, risks, and benefits of treatment. In my opinion, the patient can benefit from a guardian or POA [Power of Attorney]. The mental status exam noted the resident's insight and judgment were impaired due to dementia. Review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] showed a BIMS score of 0 (severe cognitive impairment), the resident exhibited inattention and disorganized thinking behavior that fluctuates (comes and goes, changes in severity). The resident had physical and verbal behavioral symptoms toward others for 1 to 3 days of the 6-day observation period. This behavior significantly interfered with the resident's participation in activities or social interactions. The resident rejected care for 1 to 3 days of the 6-day observation period. The resident wandered daily, and the wandering placed the resident at significant risk of getting to a potentially dangerous place. The resident was independent with all Activities of Daily Living (ADL's) except for needing supervision to shower/bathe. The resident had an active diagnosis of dementia. Review of Resident #3's care plan initiated on 2/20/24 revealed exit seeking behavior related to dementia and behaviors. Resident #3 was documented on the care plan as an elopement risk with goals to always keep the resident safe and to decrease exit seeking by 50% through the next review date (target date 5/20/2024). Resident #3's interventions included: redirect resident away from exits, encourage attendance at group activities, place resident's picture and information in elopement book, ensure all staff aware of exit seeking behavior, and other: secure unit. The bottom of the care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed Resident #3's problems included few relationships, self-isolation, anger at self or others, impaired concentration and difficulty making decisions related to a mood disorder. The goal for this care plan was try to engage Resident #3 in activities (target date 5/20/2024). The interventions included: look for opportunities to help the resident see there are choices that can be used to control life, listen with patience, and compassion, and acknowledge sadness, irritability, or withdrawal. The bottom of this care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed the resident had behavior issues related to being socially inappropriate, physically abusive, verbally abusive, wandering, sexually inappropriate, resistive to care, hoarding, and a propensity for taking things that belonged to others. The goal for this care plan was to not harm self or others and to redirect and encourage activity involvement (target date 5/20/2024). The interventions included: administer and monitor the effectiveness and or side effects of medications as ordered, intervene to protect the rights and safety of others, approach in calm manner, provide psych consult and psychological counseling. The bottom of this care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed Resident #3 required long term care in a secured unit with a risk/challenge of unsafe discharge. The goal documented Resident #3 was not safe to transition to a lesser level of care and would remain in the secured unit until the next review date of 5/20/2024. The interventions included assess the needs of resident/caretaker during stay, anticipate needs and services, involve resident in discharge planning process, provide written and verbal instructions at the resident's level of understanding, assess for community resources that may be needed, and document all discharge teaching. The bottom of this care plan noted the resident was cognitively impaired. Review of Nurse's Notes revealed: 2/21/24 at 11:00 a.m. Resident #3 was alert with confusion. 2/27/24 At approximately 6 PM Resident sitting in [NAME] hall dining room after dinner. Reports sitting on edge of chair and slipped off landing on floor. Denies any pain/discomfort, able to stand by himself, and denies hitting head. Resident able to move all extremities with no limitations. Physician Assistant made aware of episode with no new orders. Call placed to family member and phone number has been disconnected. A review of an ARNP Progress Note dated 2/28/24 revealed resident was seen for a follow up visit due to fall without injury on 2/27/24. The resident was alert with confusion, resided in the secure unit and was ambulatory without assistance. Continue watchful monitoring for changes, decreased mobility, and pain. Review of Resident #3's physician's orders revealed a telephone order dated 2/29/24 to change Hydroxyzine to 25 mg every 6 hours as needed for 14 days. Review of Resident #3's Treatment Record dated 2/29/24, time not legible showed Hydroxyzine 25mg was administered once. No additional notes were present in the medical record to indicate why the medication was administered on 2/29/24 or if it was effective. A review of a Physician Progress Note dated 3/4/24 revealed resident was seen for capacity to manage benefits. Resident oriented to self only, unsure of date, location, or circumstances. Pleasantly confused. The physician documented given degree of dementia/loss of insight, do not feel he has capacity to manage own benefits . Review of Resident #3's Nurse's Medication Notes and PRN documentation, dated 3/6/24 at 9:00 a.m. showed Hydroxyzine 25 mg was administered for increased anxiety. No additional information was present in the medical record related to the signs and symptoms of the anxiety and if the medication was effective. Review of a document, signed by Resident #3's physician dated 3/6/24 at 6PM, revealed the resident has a diagnosis of moderate dementia with behavioral disturbance, and the resident could not determine for himself whether examination was necessary; and there was substantial likelihood that without care or treatment the individual would cause serious bodily harm to self and others in the near future as evidenced by combative behavior with staff and law enforcement officer. The resident refused to return to the facility and the secure unit. The sources providing this evidence included the physician, Director of Nursing (DON) and the Nursing Home Administrator (NHA). No additional notes could be found in the medical record pertaining to an event prompting this involuntary transfer to the hospital for evaluation on 3/6/24 at 6:00 PM. A review of the facility's March 2024 Event Log used to document resident related incidents revealed no entry related to Resident #3. A tour of the facility on 03/27/2024 beginning at 9:00 a.m. revealed the secured unit where Resident #3 resided was located within the facility's [NAME] wing. The secured unit consisted of 10 resident rooms with two locked exit doors leading directly to the exterior of the facility with no patio or fencing. One of the two exit doors was located inside of the dining room used by the secure unit. This exit door had the ability to release after pushing on the bar and an alarm would sound to notify staff. A staff member was present in the unit with the assignment of door monitor. A review of the resident census on 3/6/2024 revealed 15 residents were living on the secured unit. A review of the 3/6/2024 Daily Staffing Assignment Sheet revealed the [NAME] wing had 2 licensed nurses and 3 Certified Nursing Assistants (CNA's) working on the 3:00 PM - 11:00 PM shift. The total resident census on 3/6/2024 for the [NAME] wing was 41 with 15 of the 41 residents residing on the secured unit. A telephone interview was conducted on 3/27/24 at 11:24 a.m. with the facility's Speech Therapist (ST). She said while leaving a local grocery store on 3/6/24 at approximately 5:30 PM she saw Resident #3 on the grassy area near the store's parking lot. She immediately called her manager, the Director of Rehabilitation (DOR) to see if the resident had been discharged from the facility. She reported seeing the resident from a distance and did not see a shopping cart near him. She thought the resident was wearing a long sleeve shirt, pants, and footwear. The ST reported that the DOR said he was pulling into the parking lot and visualized Resident #3. Once she knew the DOR was present, she left the parking lot and did not make contact with the resident during the observation. An interview was conducted on 3/27/24 at 10:44 a.m. with the DOR. The DOR stated the ST called him on 3/6/2024 after 5:00 p.m. and said she saw Resident #3 in the local grocery store parking lot. He called the NHA to confirm the resident had not been discharged from the facility. The DOR reported he was on his way to the local grocery store that day and approached Resident #3 around 5:24 PM. The resident was pushing a grocery cart on the sidewalk and had a black grocery bag. The DOR was unsure of the bag's contents. The DOR said Resident #3 was pleasant and not combative and went into the DOR's vehicle willingly without incident. The DOR drove the resident back to the facility. While in the vehicle Resident #3 told the DOR he was out of the facility for about 3 hours and was thirsty. The DOR reported the resident was dressed appropriately for the weather. After returning to the facility, the DOR provided fluids to the resident shortly after returning to the facility and escorted the resident back to the secured unit with the Assistant Director of Nursing (ADON). The DOR said there were two routes the resident may have taken to get to the local grocery store and assumed the resident traveled down County Road because it was a straight shot from the facility. Observation of the route likely traveled by Resident #3 from the facility to the local grocery store located at 1491 Main Street in Dunedin, Florida revealed it was 0.8 miles and approximately an 18-minute walk from the facility. The resident likely walked: 1. East on San [NAME] Drive toward Scotswood Glen for 0.4 miles. This is a 2-lane road located in front of the facility. 2. Turn right onto [NAME]/County Road 1 for approximately 0.3 miles. This is a four-lane road with turning lanes at the intersection. 3. Continue on [NAME] Rd for 469 ft. to the intersection of Main Street. There are six lanes going east and west with 4 turning lanes at this intersection. There are two lanes going north and south with one turning lane at the intersection. The speed limit was 45 miles per hour and the resident would have had to cross this intersection. 4. Turn left and travel 250 ft on Main Street 5. Turn right 100 ft into parking lot 6. Turn left and walk for about 280 ft to reach the entrance to the local grocery store. Observation of this route and shopping plaza on 3/28/24 revealed this was a highly traveled area with busy traffic and uneven terrain and obstacles like curbs and parking bumpers. The temperature in Dunedin, FL on 3/6/24 at approximately 5:00 PM was 72 degrees with no rain. On 3/27/24 at 2:13 p.m. a follow-up interview was conducted with the DOR (in the company of the NHA, DON, and ADON). The DOR confirmed Resident #3 did not display any behaviors when they returned to the facility from the local grocery store. He gave Resident #3 snacks and was unsure what happened to cause Resident #3 to dash out the door, leaving the facility a second time through the secured unit dining room door. A telephone interview was conducted on 3/27/24 at 10:59 a.m. with Staff E, CNA. Staff E said she worked on 3/6/24 and was assigned to care for Resident #3 during the 3:00 PM -11:00 PM shift. Staff E had witnessed the resident trying to leave the facility and stating he wanted to go to Daytona prior to the 3/6/2024 event. He was usually redirected when offered snacks and fluids. Staff E recalled on the day of the elopement, Resident #3 was stating he wanted to go back to Daytona, and she told him to talk to the staff about it tomorrow. Staff E said she last saw the resident on 3/6/2024 at approximately 3:45 PM, but stated at about 3:45 PM she heard the secured unit dining room door alarm going off while she was providing care to another resident. Staff E said she poked her head out of the room of the resident she was caring for and saw Staff A, Registered Nurse (RN) in the hallway. Staff A told Staff E, she would take care of that. Staff E assumed Staff A, RN meant the alarm and would determine the cause of the alarm. She did not follow up with the RN following this and reported she was unaware Resident #3 was out of the building until he was returned around 5:20 PM that evening. Staff E stated he must have left through the dining room door. Staff E stated Resident #3 was aggressive, angry, and upset upon his return. She was not asked to provide the resident with any additional supervision or services. Approximately 5-10 minutes after he had returned to the building, he went out the same door again. He eloped twice that day. The second time he was in the road in front of the facility. They could not redirect him, the local law enforcement and paramedics were called. It was very bad. Staff E said the facility does not have enough staff and reported having 13 residents on the secured unit the day Resident #3 eloped twice. Staff E reported that a second CNA was assigned to care for the remaining 2 residents on the secured unit along with additional residents outside of the secured unit. Staff E reported the Licensed Nurse assigned to the secured unit worked a split assignment between the secured unit and additional residents residing on the [NAME] wing. Staff E, CNA said often times, she was the only staff member inside the unit at any given time due to the split assignments. Since the incidents on 3/6/2024 a door monitor has been assigned to watch the emergency exit doors in the secured unit. The staff monitoring the door was not offered breaks, and the nurses do not want to sit back in the secured unit to monitor the exit doors. No additional staff outside of the door monitor had been added since the elopement occurred. Staff E stated there have been times when one CNA is assigned to all residents in the secured unit. Staff E did not feel this amount of staffing met the needs/supervision levels needed for the residents living on the secured unit. On 3/27/24 at 11:20 AM an attempt to contact Staff A, RN was made via telephone. An automated message was received saying the phone line was disconnected. Another phone number for Staff A was called on 3/29/24 at 11:19 AM. A voicemail was left but no return call was received. A telephone interview was conducted on 3/27/24 at 12:07 PM with Staff I, Licensed Practical Nurse (LPN). Staff I said on 3/6/2024 she received a phone call from the DON to check Resident #3's room, when she checked the room, the resident was not there. Staff I, LPN said she was told the resident was found at a local grocery store. When Resident #3 returned to the facility he was fine and calm. Staff I, LPN said twenty minutes later, at approximately 6:00 p.m., she was outside on break and saw Resident #3, was outside the building again. He was walking by himself on the roadway at the back of the facility. Staff I, LPN said Resident #3 was carrying a drink and holding a black plastic bag with chicken. She said she called the ADON to notify her Resident #3 had eloped again. Staff I said she was unable to redirect the resident to return to the facility. Resident #3 became aggressive, combative and was walking in the middle of San [NAME] Drive and almost collided with a vehicle. Staff I, LPN, said three law enforcment officers and two Emergency Medical Service (EMS) vehicles responded to the scene for assistance. Staff I, LPN confirmed the staffing levels on the secured unit as one CNA having two residents on the secured unit close to the entrance, along with additional residents on the [NAME] Wing outside of the secured unit. The second CNA was assigned to the remainder of the residents in the secured unit. The nurse assigned to the secured unit was responsible for all residents on this unit along with additional residents outside of the unit residing on the [NAME] Wing front unit. On 3/27/24 at 2:41 p.m., a follow-up interview was conducted with Staff I, LPN. Staff I, LPN said Resident #3's 2nd elopement occurred during mealtime. Staff I, LPN said she was not sure how Resident #3 could get out of the facility a second time without supervision. Staff I, LPN reported the secured unit dining room door had been found open before. It was broken, not alarming, the door would beep randomly at times. Additionally, when the emergency doors alarm, the sound for each door was the same so you have to figure out which door was alarming. She said the facility leadership knew the secured unit dining room door was broken. Staff I said she had reported the door issues to the DON prior to the event (date unknown). On 3/28/24 at 9:01 AM, an interview was conducted with the ADON. The ADON said on 3/6/24 when the DOR returned Resident #3 to the facility from the local grocery store, the resident was walking and talking. The ADON and DOR escorted Resident #3 back to the secured unit without difficulty. The ADON said she did not assess Resident #3 and returned to her office for a short time before receiving a phone call from Staff I, LPN notifying her Resident #3 was outside of the facility behind the building. When the ADON observed Resident #3 was outside again, she went to the secured unit and observed the dining room door was open, and the alarm was sounding. Nurse A, RN was in the vicinity passing medications. The ADON said several staff members were with Resident #3 prior to her arriving on the scene including the DOR, Staff I, LPN and Staff E, CNA. Resident #3 walked on the grass and roadway to the front of the facility and crossed a two-lane road in front of the facility. The ADON said in this intersection the resident and staff who were trying to intervene were almost hit by a white vehicle in the intersection. The physician was notified, and law enforcement was contacted to transport the resident to the hospital. An interview was conducted on 3/27/24 at 1:34 PM with Staff J, CNA. Staff J said on 3/6/24 she was in the main dining room and observed staff running and screaming. Staff J was not assigned to the secured unit and normally works on the East Wing. She asked a nurse, what's going on? She heard someone say, [Resident #3] got out. Staff J, CNA said she did not observe anything but heard the secured unit dining room emergency exit door was not secure and anybody could go in and come out. Staff J, CNA said there were not enough employees. An interview was conducted on 3/28/24 at 2:38 p.m. with Resident #3's physician, who is the facility's Medical Director. Resident #3's physician said on 3/6/24, he was notified by the NHA that Resident #3 almost got out and was having behaviors. The NHA said local law enforcement and EMS had been notified. The physician/Medical Director proceeded to document the event to have the resident transported involuntarily to the hospital. Resident #3's physician said, I do not recall knowing [Resident #3] eloped to a grocery store on that day. He was not aware of the situation with the DOR transporting Resident #3 back to the facility. A follow-up interview was conducted on 3/29/24 at 3:38 p.m. with Resident #3's physician/facility Medical Director. He said after a resident elopes from the facility, he expects the resident to be returned to the secure unit and continue the measures to prevent elopement. The Medical Director said he would definitely expect an assessment to be completed after an elopement and 72-hour hourly checks. The resident's care should be documented, physician notification, and possible pharmacy and psych teams ' involvement. On 3/27/24 at 9:37 AM, an interview and observation of the secured unit was conducted with Staff M, LPN. Staff M, LPN said all staff members are expected to respond to emergency door exit alarms. The keys for the emergency exit door alarms on the secured unit are now kept on the nurses ' key ring. The key must be used to deactivate the door exit alarms. Prior to this, a code was used to deactivate the door alarms. Staff M confirmed that the staffing on the secured unit had remained unchanged post the 3/6/24 elopement, apart from the door monitor. Staff M, LPN confirmed that the nurse was still assigned to both the secured unit and the [NAME] Wing Front unit. Staff M, LPN said the residents on the secured unit are like little toddlers and must be watched all the time. On 3/27/24 at approximately 9:39 AM, an interview was conducted with Staff L, CNA. Staff L was assigned to monitor the secured unit emergency exit doors. She said Resident #3 likes to talk a lot, walks around the unit saying he wants to go to Daytona, and attempts to get out of the door. On 3/27/24 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). The DON said he completed an investigation of the event. The DON said on 3/6/24, unsure of the specific time, the NHA notified him Resident #3 was located at a local grocery store. The DON called staff at the facility and verified Resident #3 was missing from the facility. The DOR transported Resident #3 back to the facility from the grocery store, and Resident #3 refused to enter the facility. Resident #3 walked into the roadway in front of the facility. Local law enforcement officers were notified and transported to the hospital. The DON determined Staff A, RN heard the secured unit dining room emergency exit door alarm, closed the door, and deactivated the alarm. The DON said Staff A, RN did not check outside or notify facility leadership the alarm had been activated. The DON said when the emergency exit door alarms are activated the facility expects staff to respond to the alarm. Since the event, the DON said staff are expected to count all residents at the beginning of their shift. The facility's department leadership also counts residents twice daily, five times per week. The DON said new alarms were installed on the two exit doors in the secured unit after the elopement. The new alarms are louder than the previous alarms and a key is now needed to deactivate the alarm (prior to this only a code was needed to deactivate the alarm). The DON said the facility had not completed elopement drills in 2024 prior to Resident #3's elopement on 3/6/24. The DON was not aware that 2 separate elopement events occurred with Resident #3 on 3/6/24 at the time of this interview (21 days post event). An interview was cond[TRUNCATED]

Based on record review, interviews, and facility policies and procedures, the facility failed to ensure adequate supervision for post fall care for one (Resident #4) of one resident reviewed for falls of a total of eleven sampled residents. Findings include: A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of 12/30/2023 from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on 01/16/2024 at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Helped from PT therapist (physicial therapist) putting pt back in bed. Pt again said she is fine and nothing is hurting after incident. Review of a telephone order dated 01/18/2024, 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On 02/20/24 at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's 01/16/2024 fall event. On 02/21/2024 at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, 72 hours of neuro-checks. A request was made for documentation, Resident #4's 01/16 fall event report, the assessment, and neuro-checks for the 01/16/2024 fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's 01/16/2024 fall event. A review of the facility's Policies and Procedures for Falls, effective date 09/01/2023, documented an Overview: Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. A fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as the result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person if he or she had not caught him/herself, is considered a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Policy: Is to identify residents at risk for falls and establish/ modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. Procedure: A. Fall Mitigation: 1. Residents to be evaluated for fall risk on admission/re-admission, quarterly, annually or upon identification of a significant change in status. a. Fall risk is based off results of the Fall Risk Evaluation. b. Contributing factors i.e. medications, diagnosis, c. Environmental factors i.e. lighting, B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2. Update the resident care plan with interventions. C. Post Fall strategies: 1. Resident will be evaluated, and post fall care provided as indicated. 2. Initiate Neurological checks as per physician order. 3. Notify the Physician and resident representative. 4. Update Care plan with intervention(s). 5. Initiate post fall documentation daily for 72 hours. 6. Interdisciplinary team to review fall documentation. 7. Update plan of care with new interventions as appropriate D. Review fall trends monthly during QAPI meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect resident's rights to eb free from medical neglect, failed to ensure individuals employed at the facility were licensed in accordance with applicable state laws to prevent medical neglect, when the facility failed to verify the identity, credentials, and licensure of an individual (Staff A) prior to employment as a registered nurse providing care and services for 19 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #6, #8, #4, #9, and #10. The failure of ensuring an individual is licensed as a registered nurse could result in the likelihood of harm and/or death to residents due to the lack of knowledge and education of medications and medication side effects. Medication side effects can be life-threatening, such as bleeding, sudden heart palpitations with the administration of bronchodilators, injecting insulin without the knowledge or education to check insulin quality, the proper syringe use, the area of the body to inject, and the method to inject which can result in high blood sugars, gastrotomy tube [g-tube] feeding and medication administration can result in the tube becoming clogged or occluded, without verification of proper placement it can result in pulmonary aspiration, medication administration and enteral tube feeding via g-tube increases the risk of aspiration into the lungs, not having the education and training for the care and evaluation of resident receiving dialysis could result in not identifying bleeding, infection and loss of the thrill (the motion of blood flowing through), without training and education the process of cough and deep breathing exercises would be ineffective, without proper education and training the administration of an enema could result in damaged tissue in the rectum/colon, cause a bowel perforation, and infection, education for the evaluation of a nephrostomy tube could result in not identifying infection, hemorrhage and related structural problems. Findings included: Review of Staff A's personnel file documented an application for employment undated. The application listed three professional references. The file did not provide documentation of the verification of prior employment or for the professional references. Staff A's Level II background screening had a different last name from the name on the employment application, social security card, and the driver license on record. The Level II background screening also showed 'not eligible' for the status with an eligibility determination date of [DATE]. The nursing license on file was issued in the state of California and provided a different spelling of the first name from the name on the employment application and an expiration date of [DATE]. The file did not contain a nursing license issued in the state of Florida. The driver license on record was issued in 2005 in the state of North Carolina and had an expiration date of [DATE]. There were two social security cards in the file with different first names. The passport in the file showed an expiration date of [DATE]. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed the name on the application for Staff A was not licensed as a Registered Nurse in the State of Florida. Review of the California Board of Registered Nursing website (https://www.rn.ca.gov/online/verify.shtml) revealed the name on the application for Staff A was not licensed as Registered Nurse in the State of California. Review of Staff A's time clock punch in and out documented Staff A worked 19 shifts in the facility for the period of [DATE] through [DATE]. Review of the admission Record for Resident #6 documented the resident was readmitted on [DATE] with diagnoses to include heart failure (severe failure of the heart to function properly, especially as a cause of death), dysphagia (swallowing difficulties), hypothyroidism, vascular dementia, schizophrenia, bipolar disorder, mood disorder, chronic pain syndrome, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing difficulties), gastroesophageal reflux disease, atherosclerotic heart disease, anemia, anxiety disorder, insomnia, major depressive disorder, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), protein calorie malnutrition, history of falling, polyneuropathy, and encephalopathy (brain dysfunction caused by toxic exposure). Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] documented Staff A evaluated Resident #6 on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29 for pain and on 01/16 and 01/29 checked for bowel movement. Staff A administered furosemide, lactulose, lithium carb, perphenazine, senexon, spironolactone, vitamin D3, acetaminophen, albuterol, calcium, clonazepam, divalproex, on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Review of the admission Record for Resident #8 documented the resident was admitted [DATE] with diagnoses to include Alzheimer's disease, dysphagia (swallowing difficulties), hypothyroidism, gastroesophageal reflux disease, adult failure to thrive, osteoarthritis, anemia, major depressive disorder, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, and psychosis. Review of the MAR dated [DATE] to [DATE] documented Staff A administered a nutritional supplement on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Acetaminophen was administered on 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Bumetanide and lactulose were administered on 01/03, 01/16, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. One daily multivitamin and senexon were administered on 01/03, 01/08, 01/16, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. A review of Resident #9's clinical record, the face sheet, documented an admission of [DATE]. Her diagnoses list included: Muscle weakness (generalized; Anemia; Type 2 diabetes mellites; Hypomagnesemia; Essential hypertension; Colostomy; Dysphagia oropharyngeal phase; Hypokalemia; personal history of transient ischemic attack; and cerebral infarction without residual deficits. A review of Resident #9's Minimum Data Set (MDS), quarterly review dated [DATE], document a Brief Interview for Mental Status score of 11, which indicated she was mildly impaired. A review of Resident #9's physician orders included but not limited to the following: Oxygen @ 2L/min [liters per minute] via NC [nasal cannula] as needed for shortness of breath. Colostomy Care every shift. Metformin tab 500 mg [milligrams] (for Glucophage) on tablet by mouth twice daily, diagnosis DM [diabetes]. Novolog Flexpen 100 Unit/ML [units per milliliter] Insulin Aspart Solution pen-injector 100 UN [units], Fingerstick Blood Glucose Monitoring three times daily. Inject subcutaneously per sliding scale, with result, dose, site for 6:30 a.m.; 11:30 a.m.; 4:30 p.m. Sliding scale: 1-150=0U [units] 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U <70=call MD, Greater than 400 see as needed order. Novolog Flexpen 100 Unit/ML (Insulin Aspart Solution pen-injector 100 UN if BS (blood sugar) is greater than 400, inject 15 units subcutaneously as needed. A review of Resident #9's Care Plan, reflected the following: A problem / need: Resident needs assistance with ADL's (Activity of Daily Living), Total assist; Extensive assist, related to functional decline, dated [DATE]. The goal of the plan: Resident will receive a level of assistance required to maintain or improve present level. Interventions included: Ensure all needs are met; Ensure resident is dressed and groomed as appropriate; and OOB (out of bed) to geri chair for positioning. The care plan documented the Certified Nursing Assistants (CNAs) responsible for the interventions. A problem / need: Oral agent(s), related to compliance with treatment, diet, medication, dated [DATE]. The goal of the plan: Prevent crises from inadequate control of blood sugar levels, hypoglycemia. Interventions included: Timely administration of diabetic medicine. Monitor blood sugar: if outside acceptable range give ordered coverage and/or notify physician. Be alert to signs of low blood sugar; sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, seizures, increasing stupor. Hypoglycemia. Immediately check blood sugar. Give juice. If unable to drink give instant glucagon. Reassess in 10 minutes. Be alert to signs of high blood sugar: flushed dry skin, drowsiness, nausea/vomiting, abdominal pain, soft sunken eyeballs, red lips, decreased blood pressure, acetone breath. Contact physician immediately. Hyperglycemia. The care plan documented nurses, CNAs, and dietary responsible for the interventions. A problem/ need: Resident at risk for fluid /electrolyte imbalance, dated [DATE]. The goal of the plan: Lab values will remain within normal limits through next review date. Interventions included: Lab work per physician orders. Report abnormal labs to physician. Administer medications as ordered. The care plan documented nurses responsible for the interventions. A problem/ need: Bowel movements draining through the stoma and into the pouch on the abdomen, dated [DATE]. The goal of the plan: 1. Stool will be soft. 2. Odors will be minimized and eliminated. 3. Stoma site will be surrounded by healthy tissue. Interventions included: Note and report hard or pasty stool consistency. Contact the physician immediately if severe abdominal pain or distension occurs, or resident experiences more than 2-3 days of constipation. [NAME] care: Empty pouch when it is a third to half full one or more times per day as needed. Do not wait until the pouch is completely full, this can place pressure on the seal, and cause a leak. The pouch may also detach causing all of the contents to spill. Empty and clean the pouch according to manufacturer's instructions. Observe the surrounding tissue for redness, inflammation. Provide protective skin barrier cream as ordered. The care plan documented nurses responsible for the interventions. An observation was conducted on [DATE] at 12:20 p.m. Resident #9 was observed in her room, sitting in a wheelchair. Resident #9 was awake, alert, and agreed to answer questions. She stated she did not know the nurses so well, they only come if they are called by the aid. They do not have enough staff to help to take proper care of us. When the light is on, I have to wait an hour. The night shift is the worst. Resident #9 confirmed she had a colostomy. She stated, The aids change and empty it. Sometimes, I will go a whole shift and they will not look at it. When asked if the nurses provide care for her colostomy, she stated, The nurses only come when someone calls them. The aids will empty it or if there is air in it, they will take care of it. The nurse changes the colostomy when the aid tells the nurse. Resident #9 stated, My blood sugar drops at night. They will give me a peanut butter sandwich before I go to bed and that will take care of it. It goes low enough to where they have to revive me with a shot. I woke up one time with them standing over me. They have to keep a close eye on me. Normally, I am up every day, between 10:00 a.m. and 5:00 p.m. Last week, so many people called out, we did not get up. A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of [DATE] from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on [DATE] at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Help from PT [physical therapist] therapist putting pt back in bed. Pt again said she is fine, and nothing is hurting after incident. Review of a telephone order dated [DATE], 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On [DATE] at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's [DATE] fall event. On [DATE] at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, complete 72 hours of neuro-checks. A request was made for documentation of Resident #4's 01/16 fall event report, the assessment, and neuro-checks for the [DATE] fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's [DATE] fall event. A review of Resident #10's clinical chart, the face sheet, documented an admission of 08/2021, with readmission of [DATE] showed diagnoses information included: Chronic obstructive pulmonary disease, unspecified symbolic dysfunctions, dysphagia, oropharyngeal phase; muscle weakness; Hypothyroidism; Hypokalemia; and unspecified dementia. Further review of the resident's face sheet documented he had an Advanced Directive, Do Not Resuscitate (DNR) on file. A review of Nurses Notes dated [DATE], 11:55 a.m., documented: Pronounced death time 11:45 a.m., contacted family member, (name), to informed (sic) about pt (patient). Contacted (doctor's name) to also inform about his pt passed. Funeral homes (name) was contacted per pt (family member) given information. The note was unsigned. On [DATE] at 1:16 p.m., during an interview, Staff A confirmed Resident #10 expired during her shift. He was a DNR. Staff B, LPN, assisted her with the paperwork. An interview was conducted on [DATE] at 9:50 a.m. with Staff B, LPN, regarding Resident #10's death circumstances. She confirmed she was working on the date the resident passed away. She stated, he was not on her assignment. She stated, he was not doing well for a long time. He would eat on and off. He was on comfort measures only. He had orthopedic issues. They had taken his leg off. He was cantankerous on occasion. [Staff A] had him on her assignment. When asked if two nurses were to be present to pronounce the death, she stated, no, you can get an order from the doctor. Staff A said she was doing fifteen-minute checks and stated He was a DNR (Do Not Resuscitate). I called the sister, asked about funeral home arrangements. He lived a lot longer than we thought he would. A review of the Expired instructions list, undated, documented the following: Expired Instructions: 1. Telephone order to pronounce and release body date time on form. 2. AHCA form completed, and copy given/sent to family (front and back). 3. Mortian (sic) or funeral home representative signature on the record of death/ mortician receipt when body picked up. 4. Final Nursing Note including: A. Time found and circumstances around finding resident. B. Time MD (medical doctor) called. C. Time telephone order received. D. Time family notified and who was notified. E. Time funeral home called and which funeral home and name of person receiving call. F. Note to include that body pronounced with absence of vital signs and respirations by auscultation noted by 2 nurses (do not put names on chart). On [DATE] at 1:33 p.m., during an interview, the Director of Nursing (DON) stated there was no death protocol. The expiration sheet is just instructions for nursing and staff should follow it as much as they can. The order was mandatory because they need an order to release the body. There should be a note about what happened. One person can pronounce a body as an RN. An RN can pronounce, but a CNA cannot. He confirmed Staff A pronounced this resident's death and confirmed her handwriting. On [DATE] at 3:06 p.m., Staff B, Licensed Practical Nurse (LPN), stated she knew the employee [Staff A]. She was always on the work schedule. Staff A was usually scheduled on the day shift and was assigned to the low numbers. She administered medications including insulin and did wound care. If someone had a fall, she was responsible for checking them out. She would be responsible for anything the rest of the nurses were responsible for. They would work the same shifts and were on the same team but responsible for different ends of the hall. Staff B, LPN, reported she thought it was interesting that Staff A worked as a nurse but drove a very expensive car and had told her she was married to a professional football player. Staff B said things she was saying were not adding up, so some of the staff members decided to do an internet search. On [DATE] at 3:22 p.m., Staff H, LPN, stated she worked with Staff A. Staff A shadowed under her on her first day of work for one shift. She got on the cart with her and introduced her to the residents. Staff H, LPN, reported she spent the day with her, but she was in charge of the medication cart. She saw her on the cart by herself. Her stories were extreme. Staff A was telling staff she had a boyfriend that played professional football, kids drove expensive cars, and she was taking everyone to the Superbowl. After the extreme storytelling, people started looking up her name on the internet. Staff H said she had stuff in her background that was unusual like arrests, stating The information was passed around the facility and you didn't have to look hard for it. It was a massive thing, and everyone was talking about it. Staff H, LPN, stated she took the information to the Director of Nursing. She showed him on a Saturday ([DATE]th). He said maybe it was not the same person and didn't say too much about it. He said they would look into it. On [DATE] at 11:51 a.m., during an interview with Staff E, Staffing Coordinator, she stated she would ask Staff A to pick up shifts and to stay over sometimes. If she asked her to stay over, she would but she wouldn't work past 6 or 7 p.m. Staff A worked as a Registered Nurse (RN). She worked through the week and every other weekend. Staff A would be responsible for 25 residents at the most. She worked on the 100s side (East Wing) most of the time. On [DATE] at approximately 10:54 a.m., an interview was conducted with Staff E, Staffing Coordinator, while reviewing Staff A's clock in/ out record. The Staffing Coordinator confirmed Staff A's record reflected she had clocked in on [DATE] at 6:15 a.m. and clocked out on [DATE] at 12:00 p.m. (Photographic evidence obtained). On [DATE] at 2:16 p.m., the former Human Resource (HR) Director was interviewed via phone. She stated she received training on the job but due to a change in ownership it was training during experience. She had training previously as an HR Director, but she was in restaurant management. She had experience with hiring and onboarding, but no experience with healthcare human resources. The former HR Director stated she was terminated because there was an RN hired in late December that did not have a nursing license. When the initial onboarding was happening, they switched to an electronic system, and she did not have access to run a background check and confirmed her (Staff A) license was not verified. She said she was terminated because of not verifying Staff A's nursing license and she confirmed she had no copy of the original background check that was ran prior to hiring her. She said they were pushing her to hire staff, stating I was pressured to hire as quickly as possible. Continuing, the former HR Director said she did not have full access to do the background check. The former HR Director said the system changed around the time Staff A was hired. All onboarding documents were submitted by the employees themselves. They had to upload a form of identification, social security card, or passport. In the portal at the facility level, she could not review any of those documents at that time. Staff A's interview was scheduled by the Regional HR employee. The Regional HR employee sent over her interview time and the former HR director, and the former Administrator conducted the interview. Staff A did not present a nursing license to her. She said new hires have to upload their license in the onboarding system. Due to the level of restriction on their access, it was her assumption that corporate would look through it before they activated that employee. The DON reported the concern to her about the article they saw online. They reviewed her profile and when looking at the nursing license, they discovered it was photoshopped. The level II background screening also showed not eligible. After that, the investigation was initiated. This was immediately reported to the Administrator. Staff A was working on the floor at this time and the DON pulled her from the floor into the office and questioned her about what they were seeing on the internet. Staff A told them she was in the process of receiving a compact license. The former HR Director said at the time she was hired; her license should have been checked when the licenses were being uploaded in the onboarding software. There should have been a verification that she could practice here and that did not happen. She said they did not do reference verification and she was never informed she had to check references. On [DATE] at 3:49 p.m., during an interview, the DON reported [DATE] was his start date at the facility. He confirmed Staff A was at some point assigned to each resident in the facility. He said he was a part of the investigation, and he did not believe families had been notified. The DON said he was in the facility when the concern was brought to his attention, confirming it was on a Saturday, the 27th during the afternoon shift. Staff H, LPN, came to him and shared with him an internet search that could have been her or may not have been her. He said he reported it on Monday morning to the Administrator, saying an internet search revealed information related to Staff A working in a medical office and falsifying scripts. He said he did not want to start a rumor, but the photo certainly looked like her. The DON said he walked Staff A out of the door on [DATE]. He said he did not audit narcotics counts during the time period she worked, rather he audited by looking at narcotics to make sure they were signed off. The DON reported he did not interview the residents about care or assessments, but confirmed a general assessment was done on the residents, which included asking if they felt like they were abused. On [DATE] at 4:24 p.m., during an interview the Medical Director (MD) stated he received a call from his nurse practitioner about a concern with Staff A's license and over the next day or two, he learned Staff A was terminated. The MD said the facility staff had an impromptu QAPI meeting and he attended via phone on the 31st. They became aware that someone was hired without appropriate credentials and an appropriate license. There was going to be a retroactive plan to ensure everyone's license was up to date and hiring moving forward to make sure their credentials were in place. The MD reported he worked with Staff A several times. They discussed patients in the nursing station, order changes, plans of care, and her impression of how residents were. It was his expectation that all employees have a valid license, and it was the facility's responsibility to ensure Staff A had a valid license to practice in Florida. His expectation was that the building [facility] would complete whatever background checks were needed and the license was not restricted. The MD stated it is important that a person providing care, with the nature of working in a skilled nursing facility with people with issues who are already prone to dying have the appropriate license. They need to have proper training to administer medications in a manner that was safe to maximize the safety of people receiving care. On [DATE] at 1:16 p.m., Staff A was interviewed via phone. She said her assignment varied on the dates she worked and confirmed she worked on both wings in the facility. She said she was trained for two days and was oriented by another LPN. Staff A confirmed she was terminated because her nursing license from California was under her old name, and she was denied on the background screening. She stated they found some things in her background, but she admitted everything, saying she was not guilty because it was not proven. She confirmed she was arrested but she fought the case and was found not guilty. On [DATE]th, she clocked in and left around 12 in the afternoon. She did medication pass, and after that the DON called her to the HR office. They asked her questions about the background check. The DON mentioned the prior arrest and she confirmed the last place of employment using her nursing license was in Nevada. On [DATE] at 12:22 p.m., during an interview the Administrator reported the Level II background screening showed a different last name from the name on the job application. She said verifying references was a part of the hiring process, but she was not sure if they were verified for Staff A. She said once everything was completed and uploaded, HR was responsible for verifying the documents. They should verify the background check, do the I-9, and all the other paperwork. The Administrator said the former HR Director gave Staff A the ok to start without a background check verification. On [DATE] at 1:57 p.m., during an interview the Administrator reported she came on board at the facility on [DATE]nd. She said she was not familiar with Staff A and had only met her in passing in the hallway; she worked during the day. The Administrator said on the morning of [DATE]th, the former HR Director reported to her that she had an issue and she (the Administrator) needed to come to her office. The DON was in the HR Director's office also and said staff over the weekend had done an internet search on Staff A and discovered drug charges from North Carolina. The DON said it was first brought to his attention, on Saturday or Sunday. One of the nurses told him they looked her up on the internet and showed him. The Administrator said the former HR Director pulled up the information and she told her to pull her background screening up. The background screening showed Staff A was not eligible from [DATE] for employment. The Administrator said she stated, What is she doing in this facility? She can't be here because she doesn't have a clear background check. She said she told the DON he needed to go get her because she was working that morning. The DON brought her into the office. The Administrator told her what was found, and Staff A said she wasn't charged with anything. She also told Staff A that her background check was not clear. With charges for drug trafficking with opioids and a Level II that had not cleared, she was not eligible to work; she was suspended and terminated the same day within hours of each other for multiple reasons. The Administrator said they terminated her based on what she found on the criminal charges online was multiple pages and falsification of forms, the social security cards she provided had different names and different signatures, and they were not sure Staff A was the person she said she was. The California nursing license also had a different name, and the type and the font were not the same. At that point she said she called Staff I, Chief People Officer (CPO) to review the documents. The former HR Director said she thought California was a compact state. The Administrator reported she searched for a nursing license in Nevada, North Carolina, and California, and different names came up from the name she put on the job application. So then, she searched for her name in Las Vegas and California. The Administrator said the most concerning of all the public records was she forged prescription forms in [NAME] and the document said, do not hire this person she had a checkered pass. She had multiple charges in North Carolina with 8 mugshots and they had an active warrant on her. The Administrator said she filed a report with law enforcement on [DATE]th at 1:30 p.m. Law enforcement reported Staff A had active arrest warrants in Nevada and North Carolina. The Administrator confirmed she completed a Federal Report. On [DATE] at 4:03 p.m., during an interview Staff I, Chief People Officer (CPO), reported her role was the global HR person for the company. She said a nursing license can be uploaded but HR or the Administrator must validate it. Staff I stated she believed Staff F, Director of Labor Management, activated Staff A. The I-9 form was dated [DATE], and she should not have worked prior to this date. Staff I said the Level II background screening should have been obtained prior to starting work in the facility. The former HR Director should have made sure there was a signed attestation, went into the background screening portal to pull the background screening, and made sure fingerprints were done to make sure they are compliant. Staff I stated, You can't have someone working and then pull their background. Staff I stated, For this lady, if she started on the 28th and I-9 was not signed until after that is a red flag. She should not have been working on the 28th because she had not filled everything out. She said she believed it was the 29th [January] she was informed about her license, and they started their investigation. Staff I said they have changed two things. First there is an obligation that all data like a background is uploaded so that they have proof when it was printed, including licenses, that it are Florida specific or if they are a part of a compact state. They have been given the green light to hire an HR person to audit facilities and that person started on the past Monday. She said it is a second pair of eyes to trust and verify their audits and to make sure nothing is coming up on the screening roster. The facility just hired a new [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure policies and procedures were implemented to prohibit and prevent medical neglect when failing to ensure individuals employed at the facility were licensed in accordance with applicable state laws, when the facility failed to verify the identity, credentials, and licensure of an individual (Staff A) prior to employment as a registered nurse providing care and services for 19 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #6, #8, #4, #9, and #10. The failure of ensuring an individual is licensed as a registered nurse could result in the likelihood of harm and/or death to residents due to the lack of knowledge and education of medications and medication side effects. Medication side effects can be life-threatening, such as bleeding, sudden heart palpitations with the administration of bronchodilators, injecting insulin without the knowledge or education to check insulin quality, the proper syringe use, the area of the body to inject, and the method to inject which can result in high blood sugars, gastrotomy tube [g-tube] feeding and medication administration can result in the tube becoming clogged or occluded, without verification of proper placement it can result in pulmonary aspiration, medication administration and enteral tube feeding via g-tube increases the risk of aspiration into the lungs, not having the education and training for the care and evaluation of resident receiving dialysis could result in not identifying bleeding, infection and loss of the thrill (the motion of blood flowing through), without training and education the process of cough and deep breathing exercises would be ineffective, without proper education and training the administration of an enema could result in damaged tissue in the rectum/colon, cause a bowel perforation, and infection, education for the evaluation of a nephrostomy tube could result in not identifying infection, hemorrhage and related structural problems. Findings included: Review of Staff A's personnel file documented an application for employment undated. The application listed three professional references. The file did not provide documentation of the verification of prior employment or for the professional references. Staff A's Level II background screening had a different last name from the name on the employment application, social security card, and the driver license on record. The Level II background screening showed 'not eligible' for the status with an eligibility determination date of [DATE]. The nursing license on file was issued in the state of California and provided a different spelling of the first name from the name on the employment application and an expiration date of [DATE]. The file did not contain a nursing license issued in the state of Florida. The driver license on record was issued in 2005 in the state of North Carolina and had an expiration date of [DATE]. There were two social security cards in the file with different first names. The passport in the file showed an expiration date of [DATE]. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed the name on the application for Staff A was not licensed as a Registered Nurse in the State of Florida. Review of the California Board of Registered Nursing website (https://www.rn.ca.gov/online/verify.shtml) revealed the name on the application for Staff A was not licensed as Registered Nurse in the State of California. Review of Staff A's time clock punch in and out documented Staff A worked 19 shifts in the facility for the period of [DATE] through [DATE]. Review of the admission Record for Resident #6 documented the resident was readmitted on [DATE] with diagnoses to include heart failure (severe failure of the heart to function properly, especially as a cause of death), dysphagia (swallowing difficulties), hypothyroidism, vascular dementia, schizophrenia, bipolar disorder, mood disorder, chronic pain syndrome, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing difficulties), gastroesophageal reflux disease, atherosclerotic heart disease, anemia, anxiety disorder, insomnia, major depressive disorder, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), protein calorie malnutrition, history of falling, polyneuropathy, and encephalopathy (brain dysfunction caused by toxic exposure). Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] documented Staff A evaluated Resident #6 on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29 for pain and on 01/16 and 01/29 checked for bowel movement. Staff A administered furosemide, lactulose, lithium carb, perphenazine, senexon, spironolactone, vitamin D3, acetaminophen, albuterol, calcium, clonazepam, divalproex, on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Review of the admission Record for Resident #8 documented the resident was admitted [DATE] with diagnoses to include Alzheimer's disease, dysphagia (swallowing difficulties), hypothyroidism, gastroesophageal reflux disease, adult failure to thrive, osteoarthritis, anemia, major depressive disorder, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, and psychosis. Review of the MAR dated [DATE] to [DATE] documented Staff A administered a nutritional supplement on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Acetaminophen was administered on 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Bumetanide and lactulose were administered on 01/03, 01/16, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. One daily multivitamin and senexon were administered on 01/03, 01/08, 01/16, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. A review of Resident #9's clinical record, the face sheet, documented an admission of [DATE]. Her diagnoses list included: Muscle weakness (generalized; Anemia; Type 2 diabetes mellites; Hypomagnesemia; Essential hypertension; Colostomy; Dysphagia oropharyngeal phase; Hypokalemia; personal history of transient ischemic attack; and cerebral infarction without residual deficits. A review of Resident #9's Minimum Data Set (MDS), quarterly review dated [DATE], document a Brief Interview for Mental Status score of 11, which indicated she was mildly impaired. A review of Resident #9's physician orders included but not limited to the following: Oxygen @ 2L/min [liters per minute] via NC [nasal cannula] as needed for shortness of breath. Colostomy Care every shift. Metformin tab 500 mg [milligrams] (for Glucophage) on tablet by mouth twice daily, diagnosis DM [diabetes]. Novolog Flexpen 100 Unit/ML [units per milliliter] Insulin Aspart Solution pen-injector 100 UN [units], Fingerstick Blood Glucose Monitoring three times daily. Inject subcutaneously per sliding scale, with result, dose, site for 6:30 a.m.; 11:30 a.m.; 4:30 p.m. Sliding scale: 1-150=0U [units] 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U <70=call MD, Greater than 400 see as needed order. Novolog Flexpen 100 Unit/ML (Insulin Aspart Solution pen-injector 100 UN if BS (blood sugar) is greater than 400, inject 15 units subcutaneously as needed. A review of Resident #9's Care Plan, reflected the following: A problem / need: Resident needs assistance with ADL's (Activity of Daily Living), Total assist; Extensive assist, related to functional decline, dated [DATE]. The goal of the plan: Resident will receive a level of assistance required to maintain or improve present level. Interventions included: Ensure all needs are met; Ensure resident is dressed and groomed as appropriate; and OOB (out of bed) to geri chair for positioning. The care plan documented the Certified Nursing Assistants (CNAs) responsible for the interventions. A problem / need: Oral agent(s), related to compliance with treatment, diet, medication, dated [DATE]. The goal of the plan: Prevent crises from inadequate control of blood sugar levels, hypoglycemia. Interventions included: Timely administration of diabetic medicine. Monitor blood sugar: if outside acceptable range give ordered coverage and/or notify physician. Be alert to signs of low blood sugar; sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, seizures, increasing stupor. Hypoglycemia. Immediately check blood sugar. Give juice. If unable to drink give instant glucagon. Reassess in 10 minutes. Be alert to signs of high blood sugar: flushed dry skin, drowsiness, nausea/vomiting, abdominal pain, soft sunken eyeballs, red lips, decreased blood pressure, acetone breath. Contact physician immediately. Hyperglycemia. The care plan documented nurses, CNAs, and dietary responsible for the interventions. A problem/ need: Resident at risk for fluid /electrolyte imbalance, dated [DATE]. The goal of the plan: Lab values will remain within normal limits through next review date. Interventions included: Lab work per physician orders. Report abnormal labs to physician. Administer medications as ordered. The care plan documented nurses responsible for the interventions. A problem/ need: Bowel movements draining through the stoma and into the pouch on the abdomen, dated [DATE]. The goal of the plan: 1. Stool will be soft. 2. Odors will be minimized and eliminated. 3. Stoma site will be surrounded by healthy tissue. Interventions included: Note and report hard or pasty stool consistency. Contact the physician immediately if severe abdominal pain or distension occurs, or resident experiences more than 2-3 days of constipation. [NAME] care: Empty pouch when it is a third to half full one or more times per day as needed. Do not wait until the pouch is completely full, this can place pressure on the seal, and cause a leak. The pouch may also detach causing all of the contents to spill. Empty and clean the pouch according to manufacturer's instructions. Observe the surrounding tissue for redness, inflammation. Provide protective skin barrier cream as ordered. The care plan documented nurses responsible for the interventions. An observation was conducted on [DATE] at 12:20 p.m. Resident #9 was observed in her room, sitting in a wheelchair. Resident #9 was awake, alert, and agreed to answer questions. She stated she did not know the nurses so well, they only come if they are called by the aid. They do not have enough staff to help to take proper care of us. When the light is on, I have to wait an hour. The night shift is the worst. Resident #9 confirmed she had a colostomy. She stated, The aids change and empty it. Sometimes, I will go a whole shift and they will not look at it. When asked if the nurses provide care for her colostomy, she stated, The nurses only come when someone calls them. The aids will empty it or if there is air in it, they will take care of it. The nurse changes the colostomy when the aid tells the nurse. Resident #9 stated, My blood sugar drops at night. They will give me a peanut butter sandwich before I go to bed and that will take care of it. It goes low enough to where they have to revive me with a shot. I woke up one time with them standing over me. They have to keep a close eye on me. Normally, I am up every day, between 10:00 a.m. and 5:00 p.m. Last week, so many people called out, we did not get up. A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of [DATE] from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on [DATE] at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Help from PT [physical therapist] therapist putting pt back in bed. Pt again said she is fine, and nothing is hurting after incident. Review of a telephone order dated [DATE], 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On [DATE] at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's [DATE] fall event. On [DATE] at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, complete 72 hours of neuro-checks. A request was made for documentation of Resident #4's 01/16 fall event report, the assessment, and neuro-checks for the [DATE] fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's [DATE] fall event. A review of Resident #10's clinical chart, the face sheet, documented an admission of 08/2021, with readmission of [DATE] showed diagnoses information included: Chronic obstructive pulmonary disease, unspecified symbolic dysfunctions, dysphagia, oropharyngeal phase; muscle weakness; Hypothyroidism; Hypokalemia; and unspecified dementia. Further review of the resident's face sheet documented he had an Advanced Directive, Do Not Resuscitate (DNR) on file. A review of Nurses Notes dated [DATE], 11:55 a.m., documented: Pronounced death time 11:45 a.m., contacted family member, (name), to informed (sic) about pt (patient). Contacted (doctor's name) to also inform about his pt passed. Funeral homes (name) was contacted per pt (family member) given information. The note was unsigned. On [DATE] at 1:16 p.m., during an interview, Staff A confirmed Resident #10 expired during her shift. He was a DNR. Staff B, LPN, assisted her with the paperwork. An interview was conducted on [DATE] at 9:50 a.m. with Staff B, LPN, regarding Resident #10's death circumstances. She confirmed she was working on the date the resident passed away. She stated, he was not on her assignment. She stated, he was not doing well for a long time. He would eat on and off. He was on comfort measures only. He had orthopedic issues. They had taken his leg off. He was cantankerous on occasion. [Staff A] had him on her assignment. When asked if two nurses were to be present to pronounce the death, she stated, no, you can get an order from the doctor. Staff A said she was doing fifteen-minute checks and stated He was a DNR (Do Not Resuscitate). I called the sister, asked about funeral home arrangements. He lived a lot longer than we thought he would. A review of the Expired instructions list, undated, documented the following: Expired Instructions: 1. Telephone order to pronounce and release body date time on form. 2. AHCA form completed, and copy given/sent to family (front and back). 3. Mortian (sic) or funeral home representative signature on the record of death/ mortician receipt when body picked up. 4. Final Nursing Note including: A. Time found and circumstances around finding resident. B. Time MD (medical doctor) called. C. Time telephone order received. D. Time family notified and who was notified. E. Time funeral home called and which funeral home and name of person receiving call. F. Note to include that body pronounced with absence of vital signs and respirations by auscultation noted by 2 nurses (do not put names on chart). On [DATE] at 1:33 p.m., during an interview, the Director of Nursing (DON) stated there was no death protocol. The expiration sheet is just instructions for nursing and staff should follow it as much as they can. The order was mandatory because they need an order to release the body. There should be a note about what happened. One person can pronounce a body as an RN. An RN can pronounce, but a CNA cannot. He confirmed Staff A pronounced this resident's death and confirmed her handwriting. On [DATE] at 3:06 p.m., Staff B, Licensed Practical Nurse (LPN), stated she knew the employee [Staff A]. She was always on the work schedule. Staff A was usually scheduled on the day shift and was assigned to the low numbers. She administered medications including insulin and did wound care. If someone had a fall, she was responsible for checking them out. She would be responsible for anything the rest of the nurses were responsible for. They would work the same shifts and were on the same team but responsible for different ends of the hall. Staff B, LPN, reported she thought it was interesting that Staff A worked as a nurse but drove a very expensive car and had told her she was married to a professional football player. Staff B said things she was saying were not adding up, so some of the staff members decided to do an internet search. On [DATE] at 3:22 p.m., Staff H, LPN, stated she worked with Staff A. Staff A shadowed under her on her first day of work for one shift. She got on the cart with her and introduced her to the residents. Staff H, LPN, reported she spent the day with her, but she was in charge of the medication cart. She saw her on the cart by herself. Her stories were extreme. Staff A was telling staff she had a boyfriend that played professional football, kids drove expensive cars, and she was taking everyone to the Superbowl. After the extreme storytelling, people started looking up her name on the internet. Staff H said she had stuff in her background that was unusual like arrests, stating The information was passed around the facility and you didn't have to look hard for it. It was a massive thing, and everyone was talking about it. Staff H, LPN, stated she took the information to the Director of Nursing. She showed him on a Saturday ([DATE]th). He said maybe it was not the same person and didn't say too much about it. He said they would look into it. On [DATE] at 11:51 a.m., during an interview with Staff E, Staffing Coordinator, she stated she would ask Staff A to pick up shifts and to stay over sometimes. If she asked her to stay over, she would but she wouldn't work past 6 or 7 p.m. Staff A worked as a Registered Nurse (RN). She worked through the week and every other weekend. Staff A would be responsible for 25 residents at the most. She worked on the 100s side (East Wing) most of the time. On [DATE] at approximately 10:54 a.m., an interview was conducted with Staff E, Staffing Coordinator, while reviewing Staff A's clock in/ out record. The Staffing Coordinator confirmed Staff A's record reflected she had clocked in on [DATE] at 6:15 a.m. and clocked out on [DATE] at 12:00 p.m. (Photographic evidence obtained). On [DATE] at 2:16 p.m., the former Human Resource (HR) Director was interviewed via phone. She stated she received training on the job but due to a change in ownership it was training during experience. She had training previously as an HR Director, but she was in restaurant management. She had experience with hiring and onboarding, but no experience with healthcare human resources. The former HR Director stated she was terminated because there was an RN hired in late December that did not have a nursing license. When the initial onboarding was happening, they switched to an electronic system, and she did not have access to run a background check and confirmed her (Staff A) license was not verified. She said she was terminated because of not verifying Staff A's nursing license and she confirmed she had no copy of the original background check that was ran prior to hiring her. She said they were pushing her to hire staff, stating I was pressured to hire as quickly as possible. Continuing, the former HR Director said she did not have full access to do the background check. The former HR Director said the system changed around the time Staff A was hired. All onboarding documents were submitted by the employees themselves. They had to upload a form of identification, social security card, or passport. In the portal at the facility level, she could not review any of those documents at that time. Staff A's interview was scheduled by the Regional HR employee. The Regional HR employee sent over her interview time and the former HR director, and the former Administrator conducted the interview. Staff A did not present a nursing license to her. She said new hires have to upload their license in the onboarding system. Due to the level of restriction on their access, it was her assumption that corporate would look through it before they activated that employee. The DON reported the concern to her about the article they saw online. They reviewed her profile and when looking at the nursing license, they discovered it was photoshopped. The level II background screening showed not eligible. After that, the investigation was initiated. This was immediately reported to the Administrator. Staff A was working on the floor at this time and the DON pulled her from the floor into the office and questioned her about what they were seeing on the internet. Staff A told them she was in the process of receiving a compact license. The former HR Director said at the time she was hired; her license should have been checked when the licenses were being uploaded in the onboarding software. There should have been a verification that she could practice here and that did not happen. She said they did not do reference verification and she was never informed she had to check references. On [DATE] at 3:49 p.m., during an interview, the DON reported [DATE] was his start date at the facility. He confirmed Staff A was at some point assigned to each resident in the facility. He said he was a part of the investigation, and he did not believe families had been notified. The DON said he was in the facility when the concern was brought to his attention, confirming it was on a Saturday, the 27th during the afternoon shift. Staff H, LPN, came to him and shared with him an internet search that could have been her or may not have been her. He said he reported it on Monday morning to the Administrator, saying an internet search revealed information related to Staff A working in a medical office and falsifying scripts. He said he did not want to start a rumor, but the photo certainly looked like her. The DON said he walked Staff A out of the door on [DATE]. He said he did not audit narcotics counts during the time period she worked, rather he audited by looking at narcotics to make sure they were signed off. The DON reported he did not interview the residents about care or assessments, but confirmed a general assessment was done on the residents, which included asking if they felt like they were abused. On [DATE] at 4:24 p.m., during an interview the Medical Director (MD) stated he received a call from his nurse practitioner about a concern with Staff A's license and over the next day or two, he learned Staff A was terminated. The MD said the facility staff had an impromptu QAPI meeting and he attended via phone on the 31st. They became aware that someone was hired without appropriate credentials and an appropriate license. There was going to be a retroactive plan to ensure everyone's license was up to date and hiring moving forward to make sure their credentials were in place. The MD reported he worked with Staff A several times. They discussed patients in the nursing station, order changes, plans of care, and her impression of how residents were. It was his expectation that all employees have a valid license, and it was the facility's responsibility to ensure Staff A had a valid license to practice in Florida. His expectation was that the building [facility] would complete whatever background checks were needed and the license was not restricted. The MD stated it is important that a person providing care, with the nature of working in a skilled nursing facility with people with issues who are already prone to dying have the appropriate license. They need to have proper training to administer medications in a manner that was safe to maximize the safety of people receiving care. On [DATE] at 1:16 p.m., Staff A was interviewed via phone. She said her assignment varied on the dates she worked and confirmed she worked on both wings in the facility. She said she was trained for two days and was oriented by another LPN. Staff A confirmed she was terminated because her nursing license from California was under her old name, and she was denied on the background screening. She stated they found some things in her background, but she admitted everything, saying she was not guilty because it was not proven. She confirmed she was arrested but she fought the case and was found not guilty. On [DATE]th, she clocked in and left around 12 in the afternoon. She did medication pass, and after that the DON called her to the HR office. They asked her questions about the background check. The DON mentioned the prior arrest and she confirmed the last place of employment using her nursing license was in Nevada. On [DATE] at 12:22 p.m., during an interview the Administrator reported the Level II background screening showed a different last name from the name on the job application. She said verifying references was a part of the hiring process, but she was not sure if they were verified for Staff A. She said once everything was completed and uploaded, HR was responsible for verifying the documents. They should verify the background check, do the I-9, and all the other paperwork. The Administrator said the former HR Director gave Staff A the ok to start without a background check verification. On [DATE] at 1:57 p.m., during an interview the Administrator reported she came on board at the facility on [DATE]nd. She said she was not familiar with Staff A and had only met her in passing in the hallway; she worked during the day. The Administrator said on the morning of [DATE]th, the former HR Director reported to her that she had an issue and she (the Administrator) needed to come to her office. The DON was in the HR Director's office also and said staff over the weekend had done an internet search on Staff A and discovered drug charges from North Carolina. The DON said it was first brought to his attention, on Saturday or Sunday. One of the nurses told him they looked her up on the internet and showed him. The Administrator said the former HR Director pulled up the information and she told her to pull her background screening up. The background screening showed Staff A was not eligible from [DATE] for employment. The Administrator said she stated, What is she doing in this facility? She can't be here because she doesn't have a clear background check. She said she told the DON he needed to go get her because she was working that morning. The DON brought her into the office. The Administrator told her what was found, and Staff A said she wasn't charged with anything. She also told Staff A that her background check was not clear. With charges for drug trafficking with opioids and a Level II that had not cleared, she was not eligible to work; she was suspended and terminated the same day within hours of each other for multiple reasons. The Administrator said they terminated her based on what she found on the criminal charges online was multiple pages and falsification of forms, the social security cards she provided had different names and different signatures, and they were not sure Staff A was the person she said she was. The California nursing license also had a different name, and the type and the font were not the same. At that point she said she called Staff I, Chief People Officer (CPO) to review the documents. The former HR Director said she thought California was a compact state. The Administrator reported she searched for a nursing license in Nevada, North Carolina, and California, and different names came up from the name she put on the job application. So then, she searched for her name in Las Vegas and California. The Administrator said the most concerning of all the public records was she forged prescription forms in [NAME] and the document said, do not hire this person she had a checkered pass. She had multiple charges in North Carolina with 8 mugshots and they had an active warrant on her. The Administrator said she filed a report with law enforcement on [DATE]th at 1:30 p.m. Law enforcement reported Staff A had active arrest warrants in Nevada and North Carolina. The Administrator confirmed she completed a Federal Report. On [DATE] at 4:03 p.m., during an interview Staff I, Chief People Officer (CPO), reported her role was the global HR person for the company. She said a nursing license can be uploaded but HR or the Administrator must validate it. Staff I stated she believed Staff F, Director of Labor Management, activated Staff A. The I-9 form was dated [DATE], and she should not have worked prior to this date. Staff I said the Level II background screening should have been obtained prior to starting work in the facility. The former HR Director should have made sure there was a signed attestation, went into the background screening portal to pull the background screening, and made sure fingerprints were done to make sure they are compliant. Staff I stated, You can't have someone working and then pull their background. Staff I stated, For this lady, if she started on the 28th and I-9 was not signed until after that is a red flag. She should not have been working on the 28th because she had not filled everything out. She said she believed it was the 29th [January] she was informed about her license, and they started their investigation. Staff I said they have changed two things. First there is an obligation that all data like a background is uploaded so that they have proof when it was printed, including licenses, that it are Florida specific or if they are a part of a compact state. They have been given the green light to hire an HR person to audit facilities and that person started on the past Monday. She said it is a second pair of eyes to trust and verify their audits and to make sure nothing is coming up on the screening roster. The facility just hired a new HR person

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility administration failed to administer the facility in a manner to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility administration failed to ensure an employee (Staff A) had a Level II Background Screening, failed to implement policies and procedures to verify the identity, credentials and licensure of an individual (Staff A) prior to employment as a licensed practical nurse providing care and services for 19 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #6, #8, #4, #9, and #10. The failure of ensuring an individual is licensed as a registered nurse could result in the likelihood of harm and/or death to residents due to the lack of knowledge and education of medications and medication side effects. Medication side effects can be life-threatening, such as bleeding, sudden heart palpitations with the administration of bronchodilators, injecting insulin without the knowledge or education to check insulin quality, the proper syringe use, the area of the body to inject, and the method to inject which can result in high blood sugars, gastrotomy tube [g-tube] feeding and medication administration can result in the tube becoming clogged or occluded, without verification of proper placement it can result in pulmonary aspiration, medication administration and enteral tube feeding via g-tube increases the risk of aspiration into the lungs, not having the education and training for the care and evaluation of resident receiving dialysis could result in not identifying bleeding, infection and loss of the thrill (the motion of blood flowing through), without training and education the process of cough and deep breathing exercises would be ineffective, without proper education and training the administration of an enema could result in damaged tissue in the rectum/colon, cause a bowel perforation, and infection, education for the evaluation of a nephrostomy tube could result in not identifying infection, hemorrhage and related structural problems. Findings included: Review of Staff A's personnel file documented an application for employment undated. The application listed three professional references. The file did not provide documentation of the verification of prior employment or for the professional references. Staff A's Level II background screening had a different last name from the name on the employment application, social security card, and the driver license on record. The Level II background screening showed 'not eligible' for the status with an eligibility determination date of [DATE]. The nursing license on file was issued in the state of California and provided a different spelling of the first name from the name on the employment application and an expiration date of [DATE]. The file did not contain a nursing license issued in the state of Florida. The driver license on record was issued in 2005 in the state of North Carolina and had an expiration date of [DATE]. There were two social security cards in the file with different first names. The passport in the file showed an expiration date of [DATE]. Review of the Florida Department of Health licensure web site (https://mqa-internet.doh.state.fl.us/MQASearchServices/HealthCareProviders) revealed the name on the application for Staff A was not licensed as a Registered Nurse in the State of Florida. Review of the California Board of Registered Nursing website (https://www.rn.ca.gov/online/verify.shtml) revealed the name on the application for Staff A was not licensed as Registered Nurse in the State of California. Review of Staff A's time clock punch in and out documented Staff A worked 19 shifts in the facility for the period of [DATE] through [DATE]. Review of the admission Record for Resident #6 documented the resident was readmitted on [DATE] with diagnoses to include heart failure (severe failure of the heart to function properly, especially as a cause of death), dysphagia (swallowing difficulties), hypothyroidism, vascular dementia, schizophrenia, bipolar disorder, mood disorder, chronic pain syndrome, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (swallowing difficulties), gastroesophageal reflux disease, atherosclerotic heart disease, anemia, anxiety disorder, insomnia, major depressive disorder, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), protein calorie malnutrition, history of falling, polyneuropathy, and encephalopathy (brain dysfunction caused by toxic exposure). Review of the Medication Administration Record (MAR) dated [DATE] to [DATE] documented Staff A evaluated Resident #6 on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29 for pain and on 01/16 and 01/29 checked for bowel movement. Staff A administered furosemide, lactulose, lithium carb, perphenazine, senexon, spironolactone, vitamin D3, acetaminophen, albuterol, calcium, clonazepam, divalproex, on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Review of the admission Record for Resident #8 documented the resident was admitted [DATE] with diagnoses to include Alzheimer's disease, dysphagia (swallowing difficulties), hypothyroidism, gastroesophageal reflux disease, adult failure to thrive, osteoarthritis, anemia, major depressive disorder, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, and psychosis. Review of the MAR dated [DATE] to [DATE] documented Staff A administered a nutritional supplement on 01/03, 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Acetaminophen was administered on 01/16, 01/17, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. Bumetanide and lactulose were administered on 01/03, 01/16, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. One daily multivitamin and senexon were administered on 01/03, 01/08, 01/16, 01/20, 01/21, 01/22, 01/23, 01/26, and 01/29. A review of Resident #9's clinical record, the face sheet, documented an admission of [DATE]. Her diagnoses list included: Muscle weakness (generalized; Anemia; Type 2 diabetes mellites; Hypomagnesemia; Essential hypertension; Colostomy; Dysphagia oropharyngeal phase; Hypokalemia; personal history of transient ischemic attack; and cerebral infarction without residual deficits. A review of Resident #9's Minimum Data Set (MDS), quarterly review dated [DATE], document a Brief Interview for Mental Status score of 11, which indicated she was mildly impaired. A review of Resident #9's physician orders included but not limited to the following: Oxygen @ 2L/min [liters per minute] via NC [nasal cannula] as needed for shortness of breath. Colostomy Care every shift. Metformin tab 500 mg [milligrams] (for Glucophage) on tablet by mouth twice daily, diagnosis DM [diabetes]. Novolog Flexpen 100 Unit/ML [units per milliliter] Insulin Aspart Solution pen-injector 100 UN [units], Fingerstick Blood Glucose Monitoring three times daily. Inject subcutaneously per sliding scale, with result, dose, site for 6:30 a.m.; 11:30 a.m.; 4:30 p.m. Sliding scale: 1-150=0U [units] 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U <70=call MD, Greater than 400 see as needed order. Novolog Flexpen 100 Unit/ML (Insulin Aspart Solution pen-injector 100 UN if BS (blood sugar) is greater than 400, inject 15 units subcutaneously as needed. A review of Resident #9's Care Plan, reflected the following: A problem / need: Resident needs assistance with ADL's (Activity of Daily Living), Total assist; Extensive assist, related to functional decline, dated [DATE]. The goal of the plan: Resident will receive a level of assistance required to maintain or improve present level. Interventions included: Ensure all needs are met; Ensure resident is dressed and groomed as appropriate; and OOB (out of bed) to geri chair for positioning. The care plan documented the Certified Nursing Assistants (CNAs) responsible for the interventions. A problem / need: Oral agent(s), related to compliance with treatment, diet, medication, dated [DATE]. The goal of the plan: Prevent crises from inadequate control of blood sugar levels, hypoglycemia. Interventions included: Timely administration of diabetic medicine. Monitor blood sugar: if outside acceptable range give ordered coverage and/or notify physician. Be alert to signs of low blood sugar; sweating, nervousness, faintness, confusion, fatigue, weakness, headaches, inappropriate behavior, visual problems, inability to concentrate, seizures, increasing stupor. Hypoglycemia. Immediately check blood sugar. Give juice. If unable to drink give instant glucagon. Reassess in 10 minutes. Be alert to signs of high blood sugar: flushed dry skin, drowsiness, nausea/vomiting, abdominal pain, soft sunken eyeballs, red lips, decreased blood pressure, acetone breath. Contact physician immediately. Hyperglycemia. The care plan documented nurses, CNAs, and dietary responsible for the interventions. A problem/ need: Resident at risk for fluid /electrolyte imbalance, dated [DATE]. The goal of the plan: Lab values will remain within normal limits through next review date. Interventions included: Lab work per physician orders. Report abnormal labs to physician. Administer medications as ordered. The care plan documented nurses responsible for the interventions. A problem/ need: Bowel movements draining through the stoma and into the pouch on the abdomen, dated [DATE]. The goal of the plan: 1. Stool will be soft. 2. Odors will be minimized and eliminated. 3. Stoma site will be surrounded by healthy tissue. Interventions included: Note and report hard or pasty stool consistency. Contact the physician immediately if severe abdominal pain or distension occurs, or resident experiences more than 2-3 days of constipation. [NAME] care: Empty pouch when it is a third to half full one or more times per day as needed. Do not wait until the pouch is completely full, this can place pressure on the seal, and cause a leak. The pouch may also detach causing all of the contents to spill. Empty and clean the pouch according to manufacturer's instructions. Observe the surrounding tissue for redness, inflammation. Provide protective skin barrier cream as ordered. The care plan documented nurses responsible for the interventions. An observation was conducted on [DATE] at 12:20 p.m. Resident #9 was observed in her room, sitting in a wheelchair. Resident #9 was awake, alert, and agreed to answer questions. She stated she did not know the nurses so well, they only come if they are called by the aid. They do not have enough staff to help to take proper care of us. When the light is on, I have to wait an hour. The night shift is the worst. Resident #9 confirmed she had a colostomy. She stated, The aids change and empty it. Sometimes, I will go a whole shift and they will not look at it. When asked if the nurses provide care for her colostomy, she stated, The nurses only come when someone calls them. The aids will empty it or if there is air in it, they will take care of it. The nurse changes the colostomy when the aid tells the nurse. Resident #9 stated, My blood sugar drops at night. They will give me a peanut butter sandwich before I go to bed and that will take care of it. It goes low enough to where they have to revive me with a shot. I woke up one time with them standing over me. They have to keep a close eye on me. Normally, I am up every day, between 10:00 a.m. and 5:00 p.m. Last week, so many people called out, we did not get up. A review of Resident #4's clinical record revealed no presence of a face sheet or admission sheet. A review of resident #4's Minimum Data Set (MDS) record reflected an admission of [DATE] from an acute care hospital. A review of Resident #4's diagnosis list, included: Urinary tract infection, nausea, edema-bi-lower extremities; thrombocytopenia; Hypotension; Leukocytosis; and Hypothyroidism. Record review of Nurse Progress notes, unsigned entry for Resident on [DATE] at 1400: Pt (patient) fall today due to her knee gave up she said. Asked if she hit her head. Pt stated no, pt is stable and alert. No other emergency matter was taken. Help from PT [physical therapist] therapist putting pt back in bed. Pt again said she is fine, and nothing is hurting after incident. Review of a telephone order dated [DATE], 8:19 p.m., documented Resident #4 was transferred to the hospital to be evaluated and treated with the indication of edema, abdominal distension, nosebleed, and shortness of breath. On [DATE] at 1:16 p.m. Staff A was interviewed by phone. She confirmed she was working the shift Resident #4 had a fall. Staff A stated, Resident #4 had a fall. She was found on the ground. She said she was trying to grab her walker. Asked her if she was ok and if she needed to go to the hospital. At the time, she asked the nurse if she should do an incident report and she was told no unless the fall was hitting the head and lying on the floor. She asked what she needed to do to take care of the matter. Did not see her fall to the ground. The CNA (Certified Nursing Assistant) called her. Did not recall who the CNA was. They called her from the nursing station. Resident was inside her room. She was on the floor next to her bed sitting down. She said she needed help to get up. Did not call the family. Did not call the doctor. Staff A stated she was a Registered Nurse (RN), and her nursing license was from California. A review of the facility's event log reflected no documentation for Resident #4's [DATE] fall event. On [DATE] at 9:41 a.m. the Director of Nursing (DON) was interviewed. He reported the fall protocol, for a fall was to complete an event report, assessment, and if the fall was unwitnessed, complete 72 hours of neuro-checks. A request was made for documentation of Resident #4's 01/16 fall event report, the assessment, and neuro-checks for the [DATE] fall event. The DON returned to state he did not have an event report, assessment document, or neuro-checks for Resident #4's [DATE] fall event. A review of Resident #10's clinical chart, the face sheet, documented an admission of 08/2021, with readmission of [DATE] showed diagnoses information included: Chronic obstructive pulmonary disease, unspecified symbolic dysfunctions, dysphagia, oropharyngeal phase; muscle weakness; Hypothyroidism; Hypokalemia; and unspecified dementia. Further review of the resident's face sheet documented he had an Advanced Directive, Do Not Resuscitate (DNR) on file. A review of Nurses Notes dated [DATE], 11:55 a.m., documented: Pronounced death time 11:45 a.m., contacted family member, (name), to informed (sic) about pt (patient). Contacted (doctor's name) to also inform about his pt passed. Funeral homes (name) was contacted per pt (family member) given information. The note was unsigned. On [DATE] at 1:16 p.m., during an interview, Staff A confirmed Resident #10 expired during her shift. He was a DNR. Staff B, LPN, assisted her with the paperwork. An interview was conducted on [DATE] at 9:50 a.m. with Staff B, LPN, regarding Resident #10's death circumstances. She confirmed she was working on the date the resident passed away. She stated, he was not on her assignment. She stated, he was not doing well for a long time. He would eat on and off. He was on comfort measures only. He had orthopedic issues. They had taken his leg off. He was cantankerous on occasion. [Staff A] had him on her assignment. When asked if two nurses were to be present to pronounce the death, she stated, no, you can get an order from the doctor. Staff A said she was doing fifteen-minute checks and stated He was a DNR (Do Not Resuscitate). I called the sister, asked about funeral home arrangements. He lived a lot longer than we thought he would. A review of the Expired instructions list, undated, documented the following: Expired Instructions: 1. Telephone order to pronounce and release body date time on form. 2. AHCA form completed, and copy given/sent to family (front and back). 3. Mortian (sic) or funeral home representative signature on the record of death/ mortician receipt when body picked up. 4. Final Nursing Note including: A. Time found and circumstances around finding resident. B. Time MD (medical doctor) called. C. Time telephone order received. D. Time family notified and who was notified. E. Time funeral home called and which funeral home and name of person receiving call. F. Note to include that body pronounced with absence of vital signs and respirations by auscultation noted by 2 nurses (do not put names on chart). On [DATE] at 1:33 p.m., during an interview, the Director of Nursing (DON) stated there was no death protocol. The expiration sheet is just instructions for nursing and staff should follow it as much as they can. The order was mandatory because they need an order to release the body. There should be a note about what happened. One person can pronounce a body as an RN. An RN can pronounce, but a CNA cannot. He confirmed Staff A pronounced this resident's death and confirmed her handwriting. On [DATE] at 3:06 p.m., Staff B, Licensed Practical Nurse (LPN), stated she knew the employee [Staff A]. She was always on the work schedule. Staff A was usually scheduled on the day shift and was assigned to the low numbers. She administered medications including insulin and did wound care. If someone had a fall, she was responsible for checking them out. She would be responsible for anything the rest of the nurses were responsible for. They would work the same shifts and were on the same team but responsible for different ends of the hall. Staff B, LPN, reported she thought it was interesting that Staff A worked as a nurse but drove a very expensive car and had told her she was married to a professional football player. Staff B said things she was saying were not adding up, so some of the staff members decided to do an internet search. On [DATE] at 3:22 p.m., Staff H, LPN, stated she worked with Staff A. Staff A shadowed under her on her first day of work for one shift. She got on the cart with her and introduced her to the residents. Staff H, LPN, reported she spent the day with her, but she was in charge of the medication cart. She saw her on the cart by herself. Her stories were extreme. Staff A was telling staff she had a boyfriend that played professional football, kids drove expensive cars, and she was taking everyone to the Superbowl. After the extreme storytelling, people started looking up her name on the internet. Staff H said she had stuff in her background that was unusual like arrests, stating The information was passed around the facility and you didn't have to look hard for it. It was a massive thing, and everyone was talking about it. Staff H, LPN, stated she took the information to the Director of Nursing. She showed him on a Saturday ([DATE]th). He said maybe it was not the same person and didn't say too much about it. He said they would look into it. On [DATE] at 11:51 a.m., during an interview with Staff E, Staffing Coordinator, she stated she would ask Staff A to pick up shifts and to stay over sometimes. If she asked her to stay over, she would but she wouldn't work past 6 or 7 p.m. Staff A worked as a Registered Nurse (RN). She worked through the week and every other weekend. Staff A would be responsible for 25 residents at the most. She worked on the 100s side (East Wing) most of the time. On [DATE] at approximately 10:54 a.m., an interview was conducted with Staff E, Staffing Coordinator, while reviewing Staff A's clock in/ out record. The Staffing Coordinator confirmed Staff A's record reflected she had clocked in on [DATE] at 6:15 a.m. and clocked out on [DATE] at 12:00 p.m. (Photographic evidence obtained). On [DATE] at 2:16 p.m., the former Human Resource (HR) Director was interviewed via phone. She stated she received training on the job but due to a change in ownership it was training during experience. She had training previously as an HR Director, but she was in restaurant management. She had experience with hiring and onboarding, but no experience with healthcare human resources. The former HR Director stated she was terminated because there was an RN hired in late December that did not have a nursing license. When the initial onboarding was happening, they switched to an electronic system, and she did not have access to run a background check and confirmed her (Staff A) license was not verified. She said she was terminated because of not verifying Staff A's nursing license and she confirmed she had no copy of the original background check that was ran prior to hiring her. She said they were pushing her to hire staff, stating I was pressured to hire as quickly as possible. Continuing, the former HR Director said she did not have full access to do the background check. The former HR Director said the system changed around the time Staff A was hired. All onboarding documents were submitted by the employees themselves. They had to upload a form of identification, social security card, or passport. In the portal at the facility level, she could not review any of those documents at that time. Staff A's interview was scheduled by the Regional HR employee. The Regional HR employee sent over her interview time and the former HR director, and the former Administrator conducted the interview. Staff A did not present a nursing license to her. She said new hires have to upload their license in the onboarding system. Due to the level of restriction on their access, it was her assumption that corporate would look through it before they activated that employee. The DON reported the concern to her about the article they saw online. They reviewed her profile and when looking at the nursing license, they discovered it was photoshopped. The level II background screening also showed not eligible. After that, the investigation was initiated. This was immediately reported to the Administrator. Staff A was working on the floor at this time and the DON pulled her from the floor into the office and questioned her about what they were seeing on the internet. Staff A told them she was in the process of receiving a compact license. The former HR Director said at the time she was hired; her license should have been checked when the licenses were being uploaded in the onboarding software. There should have been a verification that she could practice here and that did not happen. She said they did not do reference verification and she was never informed she had to check references. On [DATE] at 3:49 p.m., during an interview, the DON reported [DATE] was his start date at the facility. He confirmed Staff A was at some point assigned to each resident in the facility. He said he was a part of the investigation, and he did not believe families had been notified. The DON said he was in the facility when the concern was brought to his attention, confirming it was on a Saturday, the 27th during the afternoon shift. Staff H, LPN, came to him and shared with him an internet search that could have been her or may not have been her. He said he reported it on Monday morning to the Administrator, saying an internet search revealed information related to Staff A working in a medical office and falsifying scripts. He said he did not want to start a rumor, but the photo certainly looked like her. The DON said he walked Staff A out of the door on [DATE]. He said he did not audit narcotics counts during the time period she worked, rather he audited by looking at narcotics to make sure they were signed off. The DON reported he did not interview the residents about care or assessments, but confirmed a general assessment was done on the residents, which included asking if they felt like they were abused. On [DATE] at 4:24 p.m., during an interview the Medical Director (MD) stated he received a call from his nurse practitioner about a concern with Staff A's license and over the next day or two, he learned Staff A was terminated. The MD said the facility staff had an impromptu QAPI meeting and he attended via phone on the 31st. They became aware that someone was hired without appropriate credentials and an appropriate license. There was going to be a retroactive plan to ensure everyone's license was up to date and hiring moving forward to make sure their credentials were in place. The MD reported he worked with Staff A several times. They discussed patients in the nursing station, order changes, plans of care, and her impression of how residents were. It was his expectation that all employees have a valid license, and it was the facility's responsibility to ensure Staff A had a valid license to practice in Florida. His expectation was that the building [facility] would complete whatever background checks were needed and the license was not restricted. The MD stated it is important that a person providing care, with the nature of working in a skilled nursing facility with people with issues who are already prone to dying have the appropriate license. They need to have proper training to administer medications in a manner that was safe to maximize the safety of people receiving care. On [DATE] at 1:16 p.m., Staff A was interviewed via phone. She said her assignment varied on the dates she worked and confirmed she worked on both wings in the facility. She said she was trained for two days and was oriented by another LPN. Staff A confirmed she was terminated because her nursing license from California was under her old name, and she was denied on the background screening. She stated they found some things in her background, but she admitted everything, saying she was not guilty because it was not proven. She confirmed she was arrested but she fought the case and was found not guilty. On [DATE]th, she clocked in and left around 12 in the afternoon. She did medication pass, and after that the DON called her to the HR office. They asked her questions about the background check. The DON mentioned the prior arrest and she confirmed the last place of employment using her nursing license was in Nevada. On [DATE] at 12:22 p.m., during an interview the Administrator reported the Level II background screening showed a different last name from the name on the job application. She said verifying references was a part of the hiring process, but she was not sure if they were verified for Staff A. She said once everything was completed and uploaded, HR was responsible for verifying the documents. They should verify the background check, do the I-9, and all the other paperwork. The Administrator said the former HR Director gave Staff A the ok to start without a background check verification. On [DATE] at 1:57 p.m., during an interview the Administrator reported she came on board at the facility on [DATE]nd. She said she was not familiar with Staff A and had only met her in passing in the hallway; she worked during the day. The Administrator said on the morning of [DATE]th, the former HR Director reported to her that she had an issue and she (the Administrator) needed to come to her office. The DON was in the HR Director's office also and said staff over the weekend had done an internet search on Staff A and discovered drug charges from North Carolina. The DON said it was first brought to his attention, on Saturday or Sunday. One of the nurses told him they looked her up on the internet and showed him. The Administrator said the former HR Director pulled up the information and she told her to pull her background screening up. The background screening showed Staff A was not eligible from [DATE] for employment. The Administrator said she stated, What is she doing in this facility? She can't be here because she doesn't have a clear background check. She said she told the DON he needed to go get her because she was working that morning. The DON brought her into the office. The Administrator told her what was found, and Staff A said she wasn't charged with anything. She also told Staff A that her background check was not clear. With charges for drug trafficking with opioids and a Level II that had not cleared, she was not eligible to work; she was suspended and terminated the same day within hours of each other for multiple reasons. The Administrator said they terminated her based on what she found on the criminal charges online was multiple pages and falsification of forms, the social security cards she provided had different names and different signatures, and they were not sure Staff A was the person she said she was. The California nursing license also had a different name, and the type and the font were not the same. At that point she said she called Staff I, Chief People Officer (CPO) to review the documents. The former HR Director said she thought California was a compact state. The Administrator reported she searched for a nursing license in Nevada, North Carolina, and California, and different names came up from the name she put on the job application. So then, she searched for her name in Las Vegas and California. The Administrator said the most concerning of all the public records was she forged prescription forms in [NAME] and the document said, do not hire this person she had a checkered pass. She had multiple charges in North Carolina with 8 mugshots and they had an active warrant on her. The Administrator said she filed a report with law enforcement on [DATE]th at 1:30 p.m. Law enforcement reported Staff A had active arrest warrants in Nevada and North Carolina. The Administrator confirmed she completed a Federal Report. On [DATE] at 4:03 p.m., during an interview Staff I, Chief People Officer (CPO), reported her role was the global HR person for the company. She said a nursing license can be uploaded but HR or the Administrator must validate it. Staff I stated she believed Staff F, Director of Labor Management, activated Staff A. The I-9 form was dated [DATE], and she should not have worked prior to this date. Staff I said the Level II background screening should have been obtained prior to starting work in the facility. The former HR Director should have made sure there was a signed attestation, went into the background screening portal to pull the background screening, and made sure fingerprints were done to make sure they are compliant. Staff I stated, You can't have someone working and then pull their background. Staff I stated, For this lady, if she started on the 28th and I-9 was not signed until after that is a red flag. She should not have been working on the 28th because she had not filled everything out. She said she believed it was the 29th [January] she was informed about her license, and they started their investigation. Staff I said they have changed two things. First there is an obligation that all data like a background is uploaded so that they have proof when it was printed, including licenses, that it are Florida specific or if they are a part of a compact state. They have been given the green light to hire an HR person to audit facilities and that person started on the past Monday. She said it is a second pair of eyes to trust a[TRUNCATED]