**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy and procedure review, the facility failed to ensure the residents were free from medical neglect when an unidentified third party contracted individual presented to the facility and without being identified, the facility could not verify the individual was licensed and had an eligible level II background screening. Findings include: Review of the facility roster for the agency staff working at the facility documented the name [Staff A's name], previously a person of interest, who worked on 03/31/2022 at 2:45 PM through 04/01/2022 at 7:15 AM. A request was made for the verification of photo identification to verify the individual who presented to the facility was Staff A and to verify the individual was licensed as a Practical Nurse and had an eligible level II background screen. None was provided. During an interview on 04/12/2022 at 3:45 PM with the Administrator, the Regional Director of Operations, and the [NAME] President Clinical, when asked the system in place to verify the employees who present from the agency, the Administrator stated, What we have, an agency portal that we are able to pull documents from. There is the license, background screening [BG] there, and usually there is a driver license photo in that system. We are verifying their license and their BG it is not that every time we are taking that driver license photo to determine if that is the same person. When asked why the photo identification, or identification is not requested of the agency staff, the Administrator stated, I don't have that answer for that. The Regional Director of Operations stated, We had a corporate meeting last week and they went over this, and it was with that guy's name [Staff A's name]. Review of a copy of Staff A's driver's license provided by the facility documented Staff A as 5'4. During an interview on 04/12/2022 at 3:37 PM with the Unit Manager for the second floor, a copy of Staff A's driver's license with a photograph of Staff A was produced for her to identify and confirm the person in the photograph was the person who worked starting 03/31/2022 at 2:45 PM. The Unit Manager (UM) looked at the photo and stated that she did not recognize the person in the photo. She was asked if a male nurse had worked recently at the facility. The UM responded that there had been none, but that there was an agency nurse that had worked the first of April and described them self as transgender stating they were transitioning from a male to female. She felt that it was unusual that the nurse stated this as she had not brought it up as a question. She stated she sat with the person and imported the information into the facility's computer system so that they could work that shift. The Director of Nursing (DON) approached and asked what was taking place. She was informed that we were discussing a question about agency staff. She was asked if there was a male nurse or transgender agency nurse that had recently worked at the facility, and she confirmed that there was someone the first of April. The Unit Manager and the DON were asked if they could describe this person. They looked at this writer (who is 5'11) and stated that the person who worked was a little shorter than you and a medium built black person. When asked if the identification of the agency person is checked and that their documents, licensure and level II background screen, are valid, the DON responded that they rely on the agency they contract with to do this. The DON made a remark stating, The staff were asking if the person is a male or female. During an interview on 4/13/2022 at approximately 12:30 PM with the Administrator, a request was made for documentation signed by Staff A. The Administrator provided documentation. The signature signed by Staff A was compared to the signed signature on Staff A's driver's license on record with the facility. The Administrator stated, They don't match while reviewing the signatures. During an interview on 04/15/2022 at 10:20 AM with the Medical Director, when asked the expectations for agency staff who present to the facility, she stated, To make sure and ensure the safety and security of the patients, they should hire more permanent staff, they should have a process to check for agency staffs' identification. The facility must have a staff retention plan in place, match the employee's salary with other facilities, and make sure to check agency staffs' identification. During an interview on 04/15/2022 at approximately 10:45 AM via telephone with Staff E, Registered Nurse (RN), when asked if she worked with a person by the name of [Staff A's name] on 03/31/22 to 04/01/2022, she stated, Yes, he was about my height, I'm 5'8, he had twisted hair. I'm sure it's called something else but twisted is what I call it. The reason I remember it so well is because he had signed out an antibiotic but hadn't administered it. I asked him about it, and he seemed very nervous. So, I asked him again as I needed to give it to the resident, but I didn't want to do that if he had actually given it. He said no, I didn't give it. I don't remember his name. It was something like [similar names voiced], but not [first name of Staff A], I really don't recall. Review of the Interview Record Form dated 04/12/2022 documented: Date of Event 3/31/22 - 4/1/22, [Staff B's name], RN, employee, Statement written by: individual. On the evening of 03/31/2022 - agency nurse came to Unit Manager office stating that they needed to be put in the system. Agency nurse told me that they were transgender. Introduced herself as [female name] but the name [Staff A's name] is on the nursing license. Provided nursing license number. I put nurse in the PCC [point click care] system and checked with her before I left. I noted she was pleasant with our customers. Was not having any issues with PCC. Review of the Interview Record Form, dated 4/14/22, documented: Date of Event 3/31/22, Name of Person Supplying Statement: [Staff C's name], LPN [Licensed Practical Nurse], Statement being made by: Employee. Describe the circumstances of the event/incident (Who, What, Where, When and Why). On 3/31/22 at 3:15 PM, I was relieved by an agency nurse who introduced them self to me and stated, Hi, I'm [female name] and I'm a transgender. Due to this nurse (agency nurse) wearing a mask, I was unable to determine if this was a male or female nurse and if there was any facial hair noted beneath the mask. Review of the Team Member Interview/Statement Form dated 4/13/22, documented: Team Member Name/Title: [the DON's name] RN DON. Describe in detail what occurred? (Only first hand observations, not what he/she was told by someone else. If team member has no knowledge of incident that should be [not legible] documented. On 3/31/2022 I needed to give [Staff A's name] agency nurse assigned to 2 east some information. This nurse was of average height, race black. I was unable to determine if they were male or female from distance. They were I approached them as they were at the med cart noted a masculine appearance, they had a mask on per facility protocol. Their hair was in corn rows/braids. I spoke with them briefly and they stated thank you. Review of the Interview Record Form dated 04/13/22, documented: Date of Event 3/31 - 4/1/22, Name of Person Supplying Statement: [Staff D's name], LPN. On 4/1/22, as I arrived to the elevator, I observed a black male with facial hair sitting at the nursing station. He had made statements to the fact he was waiting for his relief nurse. The oncoming nurse that was assigned to take his cart had told me, that he had introduced himself as [female name] and he was a transgender. Review of the Controlled Medications Shift Accountability Record Nurse's Signature dated 3/31 for the 3-11 shift and for 3/31 the 11-7 shift documented the signature for Staff A. Review of the staffing agency documentation for Staff A, Staff A signed multiple employment forms to include a W4, I-9, Life Line Training Resources - CPR certification, ACHA (Agency for Health Care Administration) Affidavit of Compliance, etc. revealed the signatures provided on these and several other documents do not match the signature provided on the Controlled Medications Shift Accountability Record provided by the facility. Review of staffing for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:45 AM documented Staff A worked in the facility over this period of time and was assigned to provide skilled nursing services for 27 residents residing on the memory care/dementia secured unit. Dated 03/31/2022 at 2:45 PM the facility documented one third party contracted nurse and four certified nursing assistants. Dated 03/31/2022 at 10:45 PM the facility documented one third party contracted nurse and two CNAs. Review of the medical records for a sample of residents residing on the memory/dementia secured unit documented: Resident #4 was admitted into the facility on [DATE] with diagnosis of: Alzheimer's Disease [a type of dementia that affects memory, thinking and behavior], dementia, type II diabetes [impairment in the way the body regulates and uses sugar as fuel; if a diabetic's blood sugar is dangerously low it can lead to a diabetic coma. If a diabetic's blood sugar is dangerously high it can lead to coma and/or ketoacidosis, a life-threatening event when the body does not have enough insulin], hypertension [high blood pressure requiring knowledge and education of the safe blood pressure range], need for assistance with personal care, anxiety disorder [a mental health condition], long term use of insulin, dry eye syndrome, major depressive disorder [feeling of sadness and loss of interest], history of falling, restlessness and agitation, anorexia [lack or loss of appetite for food], psychotic disorder with delusions [serious mental illness in which a person cannot tell what is real from what is imagined], mixed hyperlipidemia [your blood has too many fats such as cholesterol and triglycerides]. Review of the medication administration record and the treatment administration record for Resident #4 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #4 as follows: 3/31/2022 at 4:00 PM: Docusate Sodium Tablet, Losartan Potassium [used to treat high blood pressure], Metoprolol Tartrate [used to treat high blood pressure], Trazodone HCL [used to treat depression, decrease anxiety and insomnia]. 3/31/2022 at 5:00 PM: MedPass [supplement]. 3/31/2022 at 6:00 PM Atorvastatin Calcium Tablet [used to lower bad cholesterol]. 3/31/2022 at 8:00 PM Levemir Flex Touch Solution Pen by injection [used to control high blood sugar in people with diabetes, if the blood sugar becomes dangerous low it can lead to coma, if the blood sugar is dangerously high it can lead to coma and/or ketoacidosis, a life-threatening event. If insulin is not injected into the subcutaneous tissue, it can be absorbed too quickly into the body and can lead to a low blood sugar level], Acetaminophen [pain], Accucheck to determine the blood glucose level 122 [requires education and knowledge on how to complete an accucheck and safe blood sugar result ranges]. 3/31/2022 at evening: OcuSoft Eyelid Cleansing Pad, topical. 3/31/2022 at 3-11 shift: House fungal cream to under left breast every evening shift for redness. 3/31/2022 at eve & night: Aquaphor to bilateral upper & lower extremities every shift for skin integrity. 3/31/2022 at eve & night: check for placement of adult monitoring devices. 3/31/2022 at eve & night: Skin prep to elbows, hips, coccyx and heels for preventative skin care. 4/01/2022 at 6:00 AM: Accucheck 112. Review of the medical record for Resident #14 documented the resident was admitted into the facility 03/20/2021 with diagnosis to include: type II diabetes, dementia, chronic obstructive pulmonary disease [a chronic inflammatory lung disease that causes obstructed airflow from the lungs, fibromyalgia [a condition that causes pain all over the body], cardiac arrhythmia [an irregular heartbeat], essential hypertension, major depressive disorder, long term use of insulin, adjustment disorder with depressed mood [feelings of sadness, hopelessness, crying and lack of joy from previous pleasurable things], syncope and collapse [a temporary loss of consciousness usually related to insufficient blood flow to the brain], disorientation [confused about the time, where you are or even who you are], restless leg syndrome [an uncontrollable urge to move the legs], history of transient ischemic attack [a temporary period of symptoms similar to those of a stroke, often called a mini stroke], unspecific psychosis [used if there is inadequate information to make the diagnosis of a specific psychotic disorder], esophageal reflux [the sphincter muscle at the lower end of your esophagus relaxes at the wrong time, allowing stomach acid to back up into your esophagus], atherosclerotic heart disease [a buildup of fats, cholesterol and other substances in and on your artery walls]. Review of the medication administration record and the treatment administration record for Resident #14 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #14 as follows: 03/31/2022 at 4:00 PM Cholecalciferol [supplement to treat a vitamin D deficiency], Cyanocobalamin [vitamin B12], Amlodipine [lowers blood pressure], Apixaban [blood thinner requiring knowledge of the use of the medication and assessment for bleeding], Metformin HCL [used to control high blood sugar], Depakote Sprinkles Capsule Sprinkle [treats symptoms of mania, epilepsy, and migraine prophylaxis]. 03/31/2022 at 4:30 PM Accucheck. 03/31/2022 at 8:00 PM Atorvastatin Calcium, Donepezil HCL [used to treat Alzheimer's disease], Docusate Sodium [used to treat constipation], Accucheck. 03/31/2022 Evening and Night shifts - No sting skin-prep to hip, elbow, heel, coccyx topically. 3-11 shift- Behavior assessment. 11-7 shift- Behavior assessment. 04/01/2022 at 6:30 AM Accucheck: 167, Lantus Solution by injection [long lasting insulin used to treat high blood sugar]. If insulin is not injected into the subcutaneous tissue, it can be absorbed too quickly into the body and can lead to a low blood sugar level. Review of the medical record for Resident #32 documented the resident was admitted into the facility 10/01/2021 with diagnosis to include: chronic kidney disease stage 3 [mild to moderate damage to the kidneys and they are less able to filter waste and fluid out of your blood], Alzheimer's Disease, dementia, major depressive disorder, anxiety disorder, esophageal reflux, atherosclerotic heart disease, constipation, other idiopathic peripheral autonomic neuropathy [damage of the peripheral nerves where cause cannot be determined]. Review of the medication administration record and the treatment administration record for Resident #32 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #32 as follows: 03/31/2022 at 4:00 PM Vitamin B-12, Vitamin D3. 03/31/2022 at 5:00 PM Xanax [used to treat anxiety and panic disorders]. 03/31/2022 Evening assessed for anxiety, insomnia documenting - Yes Insomnia observed, Staff A documented the resident verbalization of sad feeling/crying - Yes [there was no documentation the physician was notified of these findings]. 03/31/2022 at 8:00 PM Donepezil HCL, Gabapentin [anticonvulsant to treat seizures, off label use for neuropathy] Trazodone HCL. 04/01/2022 Night assessed for anxiety, insomnia documenting yes, insomnia observed. Night assessed and documented verbalization of sad feeling/crying - Yes [there was no documentation the physician was notified of the findings]. 03/31/2022 to 04/01/2022 Evening and Night assessed for the placement of adult monitoring device. 04/01/2022 at 6:00 AM Omeprazole [used to decrease the amount of acid in the stomach]. Review of the TERMS OF USE & MASTER STAFFING AGREEMENT by and between the third party contracted staffing agency and the facility [Client] dated March 2, 2022, as the effective date reads: 1. Staffing Services. 1.2. All HCPs [Health Care Providers] shall be independent contractors of Agency. No HCPs will be employees of Agency. 3. Client's Responsibilities. 3.1. Requesting HCPs. 3.1.1. Client will utilize Agency's web portal [web portal provided] to access Agency's supplemental staffing services and electronic timesheet system. Agency utilizes [web portal name] and electronic mail to communicate with Client the creation, cancelation, and assignment of HCPs along with application documentation for that HCP. It is Client's sole responsibility to maintain accurate designated recipients of email communication. 3.3. Monitoring HCP's. 3.3.1. Client shall provide orientation which, at minimum, includes the review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA, and EMR/Charting where applicable. HCP shall report too Client 30 minutes prior to the first scheduled shift for such orientation. 3.3.3. Client shall provide HCP all necessary equipment and software needed to perform Client's required duties. HCP will be required to follow all Client's procedures and protection protocols. IT is the sole responsibility of the Client to monitor and enforce all policies and procedures with HCP. Agency will assume no liability for any equipment, software, policies or enforcement measures provided to HCP. Review of the policy and procedure titled, Abuse, Neglect, Exploitation, Mistreatment And Misappropriation Of Resident Property, Policy No: CO-ROP. Created 05-20, Revised X reads: Preface: An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Centers for Medicaid and Medicare Services (CMS - Definitions. Definitions of Abuse and Neglect: Abuse and neglect exist in many forms and to varying degrees. The following are the approved CMS definitions of abuse and neglect from the Draft State Operations Manual Appendix PP effective November 28, 2016. F. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Abuse Policy. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Objective of Abuse Policy. The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program. Overview of the Seven Components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. Population. A. The facility's population presents the following factors, (May include, but not limited to) which could result in maltreatment of residents: The assessment, plan of care and services, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of cognitive deficits, sensory deficits, aggressive behaviors, residents who have behaviors such as entering other residents' rooms, wandering behaviors, residents with self-injurious behaviors, socially inappropriate behaviors, verbal outbursts, residents with communication disorders, those who are nonverbal and those that require heavy care and/or are totally dependent on staff. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Ad Hoc QAPI [Quality Assurance Performance Improvement] held with the leadership team to include the Medical Director on 4/12/22. Skin check audits for the 27 resident residing in the memory care unit were completed, the psychosocial status for abuse and neglect of the residents was conducted by Social Services, interviews were completed with the resident's representatives, the medication administration records were audited, narcotic count sheets were audited, audits for identification, licensure/certification, and level II background screenings were completed for all agency staff, 112 of 112 staff signed attending training on abuse/neglect/exploitation, and verification of agency staff, the Administrator and Director of Nursing received training from the Regional Team and provided training to the Assistant Director of Nursing, Social Services, and Unit Managers regarding abuse/neglect and identification verification for third party contracted staff. Interviews were conducted with the Administrator, the Director or Nursing, and the Assistant Director of Nursing to verify the training completed. Interviews were conducted with sampled seven facility and third party contracted staff to include four nurses and three certified nursing assistants regarding training in abuse, neglect, and third party contracted staff identity verification to complete verification of licensure/certification and level II background screens, and observations were conducted of third party contracted staff being identified and verified prior to access to residents.

**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 an unidentified third party contracted individual presented to the facility and without being identified, the facility could not verify the individual was licensed and had an eligible level II background screening. Findings include: Review of the job description titled, Administrator reads: Job Code: 490-1. Reports to: Regional [NAME] President. Overview: The Administrator administers, directs and coordinates all functions of the facility to assure that the highest degree of quality of care is consistently provided to the patients. Recruits and trains team members to create and maintain a highly functioning team environment and maintains high customer satisfaction. Responsibilities: Understand the facility's care regulations and support the patient care program by regularly meeting with the Patient Services Director to discuss and address concerns of the department. Constantly assess patient needs and staffing levels. Operate the facility in accordance with citadel Care Center policies and federal, state and local regulations. Maintain safe working and living environment. Assist in the Quality Assurance and Performance Improvement (QAPI) process. Supervisory Responsibilities: this position oversees all departments within the facility. Review of the job description titled, Director of Nursing reads: Job Code 125-1. Overview: Executes the goals and objectives of the nursing department in regard to patient/resident rights, patient/resident care and reflects the mission statement of the facility. Serves as a role model to nursing staff while facilitating outcomes-based care delivery, cost management, and enhanced customer satisfaction within the context of an interdisciplinary framework. Provide leadership and direction for the nursing staff while being responsible for the overall management of the Nursing Department. Ensures nursing staff's compliance with all facility and nursing policies and procedures as well as compliance with regulatory requirements. Responsibilities: Interpret and execute administrative, nursing and resident/patient care policies. Ensure compliance with government and accrediting agency standards and regulations pertaining to Nursing. Direct systems and programs within the department designed to meet regulatory standards. Assess, coordinate, plan and implement the systems required to deliver a high standard of care to patients/residents. Define, establish, implement and maintain the standards for care to be delivered Develop the policies and procedures required to meet the standards of care. Ensure that all nursing personnel comply with the written policies and procedures established by the department and the facility. Meet with staff regularly in planning the clinical services, programs and activities of the department and to identify and correct problem areas and improve services. Make reports and recommendations to the Administration concerning the activities of the department. Establish an interdisciplinary framework within which nursing services can be coordinated to ensure that residents' needs will be met. Establish and maintain qualifications and functions for each nursing position Collaborate with other departments and disciplines in meeting the residents' needs. Actively participate in committees such as QA/PI, Infection Cont4rol, Safety, Ethics, Leadership and others. Participate in QA/PI Programs by providing for the collection and analysis of data for the continuous quality improvement program. Oversee performance improvement activities as outcome measurements necessitate. Identify areas for improvement in the systems of care delivery. Participate in and adhere to employee health, safety, security, and corporate compliance programs. Supervisory Responsibilities: This position manages all employees of the Nursing department and is responsible for the performance management and hiring of the employees within that department. Review of the Medical Director Agreement Between Facility and Physician dated 10/15/2020 reads: Recitals: A. The Facility is a skilled nursing facility, located at 301 S. Bay Street, [NAME], FL 32726. The Facility requires the services of a medical director (the Medical Director) to assist the Facility in meeting the applicable standards established under applicable state and federal law. Terms: 2. Duties of Medical Director. The duties and job responsibilities of the Medical Director under this agreement are: A. Standards of Care and Clinical Programs - The Medical Director will oversee implementation and utilization of the clinical programs and nationally accepted standards of care at the Facility. The Medical Director will review and document (by signature) all new clinical policies and programs used, or proposed to be used, at the Facility and communicated to the Medical Director. B. Data Driven Quality Improvement/Risk Management. The Medical Director will be an integral part of the quality improvement process at the Facility, and will be an active member of the Facility's QI committee through active leadership participation at the monthly meetings. These duties will include regular review of the Facility Clinical Outcomes Report, the CMS Facility Quality Indicator Profile, and other clinical outcome data as appropriate. The Medical Director will provide medical guidance to leadership in addressing issues raised by outcome trends and comparisons and consult with quality improvement teams as required. In addition, the Medical Director will be actively involved in the Facility's risk management program. This will include review of all routine and adverse incident reports (to include abuse/neglect) with appropriate follow-up and recommendations as indicated. D. Accreditation/Survey. The Medical Director will ensure the overall coordination of medical care in the Facility and that clinical care programs and polices and procedures are in place that are on accordance with accreditation and survey requirements. The Medical Director will become familiar with state and federal laws and regulations regarding nursing home performance. The Medical Director will play an active role in all accreditation and survey event that occur at the Facility, especially attending exit interviews. E. Medical Services Oversight. E.1. As the Medical Director is responsible for assuring the clinical needs of Facility's customers are met, if a customer's attending physician releases the customer or the Customer request a new physician, the Medical Director will be responsible for that customer's clinical needs, until a new attending physician is chosen by the customer and the new attending physician accepts responsibility for the customer's clinical needs. G. Systems Support and Improvement. The Medical Director will monitor and identify items that help support, or that inhibit, effective, efficient care. The Medical Director will review and advise administration about the adequacy of the Facility's scope or services, equipment, environment, professional and support staff. Review of the facility roster for the agency staff working at the facility documented the name [Staff A's name], previously a person of interest, who worked on 03/31/2022 at 2:45 PM through 04/01/2022 at 7:15 AM. A request was made for the verification of photo identification to verify the individual who presented to the facility was Staff A and to verify the individual was licensed as a Practical Nurse and had an eligible level II background screen. None was provided. During an interview on 04/12/2022 at 3:45 PM with the Administrator, the Regional Director of Operations, and the [NAME] President Clinical, when asked the system in place to verify the employees who present from the agency, the Administrator stated, What we have, an agency portal that we are able to pull documents from. There is the license, background screening [BG] there, and usually there is a driver license photo in that system. We are verifying their license and their BG it is not that every time we are taking that driver license photo to determine if that is the same person. When asked why the photo identification, or identification is not requested of the agency staff, the Administrator stated, I don't have that answer for that. The Regional Director of Operations stated, We had a corporate meeting last week and they went over this, and it was with that guy's name [Staff A's name]. Review of a copy of Staff A's driver's license provided by the facility documented Staff A as 5'4. During an interview on 04/12/2022 at 3:37 PM with the Unit Manager for the second floor, a copy of Staff A's driver's license with a photograph of Staff A was produced for her to identify and confirm the person in the photograph was the person who worked starting 03/31/2022 at 2:45 PM. The Unit Manager (UM) looked at the photo and stated that she did not recognize the person in the photo. She was asked if a male nurse had worked recently at the facility. The UM responded that there had been none, but that there was an agency nurse that had worked the first of April and described them self as transgender stating they were transitioning from a male to female. She felt that it was unusual that the nurse stated this as she had not brought it up as a question. She stated she sat with the person and imported the information into the facility's computer system so that they could work that shift. The Director of Nursing (DON) approached and asked what was taking place. She was informed that we were discussing a question about agency staff. She was asked if there was a male nurse or transgender agency nurse that had recently worked at the facility, and she confirmed that there was someone the first of April. The Unit Manager and the DON were asked if they could describe this person. They looked at this writer (who is 5'11) and stated that the person who worked was a little shorter than you and a medium built black person. When asked if the identification of the agency person is checked and that their documents, licensure and level II background screen, are valid, the DON responded that they rely on the agency they contract with to do this. The DON made a remark stating, The staff were asking if the person is a male or female. During an interview on 4/13/2022 at approximately 12:30 PM with the Administrator, a request was made for documentation signed by Staff A. The Administrator provided documentation. The signature signed by Staff A was compared to the signed signature on Staff A's driver's license on record with the facility. The Administrator stated, They don't match while reviewing the signatures. During an interview on 04/15/2022 at 10:20 AM with the Medical Director, when asked the expectations for agency staff who present to the facility, she stated, To make sure and ensure the safety and security of the patients, they should hire more permanent staff, they should have a process to check for agency staffs' identification. The facility must have a staff retention plan in place, match the employee's salary with other facilities, and make sure to check agency staffs' identification. During an interview on 04/15/2022 at approximately 10:45 AM via telephone with Staff E, Registered Nurse (RN), when asked if she worked with a person by the name of [Staff A's name] on 03/31/22 to 04/01/2022, she stated, Yes, he was about my height, I'm 5'8, he had twisted hair. I'm sure it's called something else but twisted is what I call it. The reason I remember it so well is because he had signed out an antibiotic but hadn't administered it. I asked him about it, and he seemed very nervous. So, I asked him again as I needed to give it to the resident, but I didn't want to do that if he had actually given it. He said no, I didn't give it. I don't remember his name. It was something like [similar names voiced], but not [first name of Staff A], I really don't recall. Review of the Interview Record Form dated 04/12/2022 documented: Date of Event 3/31/22 - 4/1/22, [Staff B's name], RN, employee, Statement written by: individual. On the evening of 03/31/2022 - agency nurse came to Unit Manager office stating that they needed to be put in the system. Agency nurse told me that they were transgender. Introduced herself as [female name] but the name [Staff A's name] is on the nursing license. Provided nursing license number. I put nurse in the PCC [point click care] system and checked with her before I left. I noted she was pleasant with our customers. Was not having any issues with PCC. Review of the Interview Record Form, dated 4/14/22, documented: Date of Event 3/31/22, Name of Person Supplying Statement: [Staff C's name], LPN [Licensed Practical Nurse], Statement being made by: Employee. Describe the circumstances of the event/incident (Who, What, Where, When and Why). On 3/31/22 at 3:15 PM, I was relieved by an agency nurse who introduced them self to me and stated, Hi, I'm [female name] and I'm a transgender. Due to this nurse (agency nurse) wearing a mask, I was unable to determine if this was a male or female nurse and if there was any facial hair noted beneath the mask. Review of the Team Member Interview/Statement Form dated 4/13/22, documented: Team Member Name/Title: [the DON's name] RN DON. Describe in detail what occurred? (Only first hand observations, not what he/she was told by someone else. If team member has no knowledge of incident that should be [not legible] documented. On 3/31/2022 I needed to give [Staff A's name] agency nurse assigned to 2 east some information. This nurse was of average height, race black. I was unable to determine if they were male or female from distance. They were I approached them as they were at the med cart noted a masculine appearance, they had a mask on per facility protocol. Their hair was in corn rows/braids. I spoke with them briefly and they stated thank you. Review of the Interview Record Form dated 04/13/22, documented: Date of Event 3/31 - 4/1/22, Name of Person Supplying Statement: [Staff D's name], LPN. On 4/1/22, as I arrived to the elevator, I observed a black male with facial hair sitting at the nursing station. He had made statements to the fact he was waiting for his relief nurse. The oncoming nurse that was assigned to take his cart had told me, that he had introduced himself as [female name] and he was a transgender. Review of the Controlled Medications Shift Accountability Record Nurse's Signature dated 3/31 for the 3-11 shift and for 3/31 the 11-7 shift documented the signature for Staff A. Review of the staffing agency documentation for Staff A, Staff A signed multiple employment forms to include a W4, I-9, Life Line Training Resources - CPR certification, ACHA (Agency for Health Care Administration) Affidavit of Compliance, etc. revealed the signatures provided on these and several other documents do not match the signature provided on the Controlled Medications Shift Accountability Record provided by the facility. Review of staffing for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:45 AM documented Staff A worked in the facility over this period of time and was assigned to provide skilled nursing services for 27 residents residing on the memory care/dementia secured unit. Dated 03/31/2022 at 2:45 PM the facility documented one third party contracted nurse and four certified nursing assistants. Dated 03/31/2022 at 10:45 PM the facility documented one third party contracted nurse and two CNAs. Review of the medical records for a sample of residents residing on the memory/dementia secured unit documented: Resident #4 was admitted into the facility on [DATE] with diagnosis of: Alzheimer's Disease [a type of dementia that affects memory, thinking and behavior], dementia, type II diabetes [impairment in the way the body regulates and uses sugar as fuel; if a diabetic's blood sugar is dangerously low it can lead to a diabetic coma. If a diabetic's blood sugar is dangerously high it can lead to coma and/or ketoacidosis, a life-threatening event when the body does not have enough insulin], hypertension [high blood pressure requiring knowledge and education of the safe blood pressure range], need for assistance with personal care, anxiety disorder [a mental health condition], long term use of insulin, dry eye syndrome, major depressive disorder [feeling of sadness and loss of interest], history of falling, restlessness and agitation, anorexia [lack or loss of appetite for food], psychotic disorder with delusions [serious mental illness in which a person cannot tell what is real from what is imagined], mixed hyperlipidemia [your blood has too many fats such as cholesterol and triglycerides]. Review of the medication administration record and the treatment administration record for Resident #4 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #4 as follows: 3/31/2022 at 4:00 PM: Docusate Sodium Tablet, Losartan Potassium [used to treat high blood pressure], Metoprolol Tartrate [used to treat high blood pressure], Trazodone HCL [used to treat depression, decrease anxiety and insomnia]. 3/31/2022 at 5:00 PM: MedPass [supplement]. 3/31/2022 at 6:00 PM Atorvastatin Calcium Tablet [used to lower bad cholesterol]. 3/31/2022 at 8:00 PM Levemir Flex Touch Solution Pen by injection [used to control high blood sugar in people with diabetes, if the blood sugar becomes dangerous low it can lead to coma, if the blood sugar is dangerously high it can lead to coma and/or ketoacidosis, a life-threatening event. If insulin is not injected into the subcutaneous tissue, it can be absorbed too quickly into the body and can lead to a low blood sugar level], Acetaminophen [pain], Accucheck to determine the blood glucose level 122 [requires education and knowledge on how to complete an accucheck and safe blood sugar result ranges]. 3/31/2022 at evening: OcuSoft Eyelid Cleansing Pad, topical. 3/31/2022 at 3-11 shift: House fungal cream to under left breast every evening shift for redness. 3/31/2022 at eve & night: Aquaphor to bilateral upper & lower extremities every shift for skin integrity. 3/31/2022 at eve & night: check for placement of adult monitoring devices. 3/31/2022 at eve & night: Skin prep to elbows, hips, coccyx and heels for preventative skin care. 4/01/2022 at 6:00 AM: Accucheck 112. Review of the medical record for Resident #14 documented the resident was admitted into the facility 03/20/2021 with diagnosis to include: type II diabetes, dementia, chronic obstructive pulmonary disease [a chronic inflammatory lung disease that causes obstructed airflow from the lungs, fibromyalgia [a condition that causes pain all over the body], cardiac arrhythmia [an irregular heartbeat], essential hypertension, major depressive disorder, long term use of insulin, adjustment disorder with depressed mood [feelings of sadness, hopelessness, crying and lack of joy from previous pleasurable things], syncope and collapse [a temporary loss of consciousness usually related to insufficient blood flow to the brain], disorientation [confused about the time, where you are or even who you are], restless leg syndrome [an uncontrollable urge to move the legs], history of transient ischemic attack [a temporary period of symptoms similar to those of a stroke, often called a mini stroke], unspecific psychosis [used if there is inadequate information to make the diagnosis of a specific psychotic disorder], esophageal reflux [the sphincter muscle at the lower end of your esophagus relaxes at the wrong time, allowing stomach acid to back up into your esophagus], atherosclerotic heart disease [a buildup of fats, cholesterol and other substances in and on your artery walls]. Review of the medication administration record and the treatment administration record for Resident #14 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #14 as follows: 03/31/2022 at 4:00 PM Cholecalciferol [supplement to treat a vitamin D deficiency], Cyanocobalamin [vitamin B12], Amlodipine [lowers blood pressure], Apixaban [blood thinner requiring knowledge of the use of the medication and assessment for bleeding], Metformin HCL [used to control high blood sugar], Depakote Sprinkles Capsule Sprinkle [treats symptoms of mania, epilepsy, and migraine prophylaxis]. 03/31/2022 at 4:30 PM Accucheck. 03/31/2022 at 8:00 PM Atorvastatin Calcium, Donepezil HCL [used to treat Alzheimer's disease], Docusate Sodium [used to treat constipation], Accucheck. 03/31/2022 Evening and Night shifts - No sting skin-prep to hip, elbow, heel, coccyx topically. 3-11 shift- Behavior assessment. 11-7 shift- Behavior assessment. 04/01/2022 at 6:30 AM Accucheck: 167, Lantus Solution by injection [long lasting insulin used to treat high blood sugar]. If insulin is not injected into the subcutaneous tissue, it can be absorbed too quickly into the body and can lead to a low blood sugar level. Review of the medical record for Resident #32 documented the resident was admitted into the facility 10/01/2021 with diagnosis to include: chronic kidney disease stage 3 [mild to moderate damage to the kidneys and they are less able to filter waste and fluid out of your blood], Alzheimer's Disease, dementia, major depressive disorder, anxiety disorder, esophageal reflux, atherosclerotic heart disease, constipation, other idiopathic peripheral autonomic neuropathy [damage of the peripheral nerves where cause cannot be determined]. Review of the medication administration record and the treatment administration record for Resident #32 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #32 as follows: 03/31/2022 at 4:00 PM Vitamin B-12, Vitamin D3. 03/31/2022 at 5:00 PM Xanax [used to treat anxiety and panic disorders]. 03/31/2022 Evening assessed for anxiety, insomnia documenting - Yes Insomnia observed, Staff A documented the resident verbalization of sad feeling/crying - Yes [there was no documentation the physician was notified of these findings]. 03/31/2022 at 8:00 PM Donepezil HCL, Gabapentin [anticonvulsant to treat seizures, off label use for neuropathy] Trazodone HCL. 04/01/2022 Night assessed for anxiety, insomnia documenting yes, insomnia observed. Night assessed and documented verbalization of sad feeling/crying - Yes [there was no documentation the physician was notified of the findings]. 03/31/2022 to 04/01/2022 Evening and Night assessed for the placement of adult monitoring device. 04/01/2022 at 6:00 AM Omeprazole [used to decrease the amount of acid in the stomach]. Review of the TERMS OF USE & MASTER STAFFING AGREEMENT by and between the third party contracted staffing agency and the facility [Client] dated March 2, 2022, as the effective date reads: 1. Staffing Services. 1.2. All HCPs [Health Care Providers] shall be independent contractors of Agency. No HCPs will be employees of Agency. 3. Client's Responsibilities. 3.1. Requesting HCPs. 3.1.1. Client will utilize Agency's web portal [web portal provided] to access Agency's supplemental staffing services and electronic timesheet system. Agency utilizes [web portal name] and electronic mail to communicate with Client the creation, cancelation, and assignment of HCPs along with application documentation for that HCP. It is Client's sole responsibility to maintain accurate designated recipients of email communication. 3.3. Monitoring HCP's. 3.3.1. Client shall provide orientation which, at minimum, includes the review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA, and EMR/Charting where applicable. HCP shall report too Client 30 minutes prior to the first scheduled shift for such orientation. 3.3.3. Client shall provide HCP all necessary equipment and software needed to perform Client's required duties. HCP will be required to follow all Client's procedures and protection protocols. IT is the sole responsibility of the Client to monitor and enforce all policies and procedures with HCP. Agency will assume no liability for any equipment, software, policies or enforcement measures provided to HCP. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Ad Hoc QAPI [Quality Assurance Performance Improvement] held with the leadership team to include the Medical Director on 4/12/22. Skin check audits for the 27 resident residing in the memory care unit were completed, the psychosocial status for abuse and neglect of the residents was conducted by Social Services, interviews were completed with the resident's representatives, the medication administration records were audited, narcotic count sheets were audited, audits for identification, licensure/certification, and level II background screenings were completed for all agency staff, 112 of 112 staff signed attending training on abuse/neglect/exploitation, and verification of agency staff, the Administrator and Director of Nursing received training from the Regional Team and provided training to the Assistant Director of Nursing, Social Services, and Unit Managers regarding abuse/neglect and identification verification for third party contracted staff. Interviews were conducted with the Administrator, the Director or Nursing, and the Assistant Director of Nursing to verify the training completed. Interviews were conducted with sampled seven facility and third party contracted staff to include four nurses and three certified nursing assistants regarding training in abuse, neglect, and third party contracted staff identity verification to complete verification of licensure/certification and level II background screens, and observations were conducted of third party contracted staff being identified and verified prior to access to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the licensure qualifications for third party contracted staff presenting to the facility through identification verification when an unidentified third party contracted individual presented to the facility and without being identified, the facility could not verify the individual was licensed and had an eligible level II background screening. Findings include: Review of the facility roster for the agency staff working at the facility documented the name [Staff A's name], previously a person of interest, who worked on 03/31/2022 at 2:45 PM through 04/01/2022 at 7:15 AM. A request was made for the verification of photo identification to verify the individual who presented to the facility was Staff A and to verify the individual was licensed as a Practical Nurse and had an eligible level II background screen. None was provided. During an interview on 04/12/2022 at 3:45 PM with the Administrator, the Regional Director of Operations, and the [NAME] President Clinical, when asked the system in place to verify the employees who present from the agency, the Administrator stated, What we have, an agency portal that we are able to pull documents from. There is the license, background screening [BG] there, and usually there is a driver license photo in that system. We are verifying their license and their BG it is not that every time we are taking that driver license photo to determine if that is the same person. When asked why the photo identification, or identification is not requested of the agency staff, the Administrator stated, I don't have that answer for that. The Regional Director of Operations stated, We had a corporate meeting last week and they went over this, and it was with that guy's name [Staff A's name]. Review of a copy of Staff A's driver's license provided by the facility documented Staff A as 5'4. During an interview on 04/12/2022 at 3:37 PM with the Unit Manager for the second floor, a copy of Staff A's driver's license with a photograph of Staff A was produced for her to identify and confirm the person in the photograph was the person who worked starting 03/31/2022 at 2:45 PM. The Unit Manager (UM) looked at the photo and stated that she did not recognize the person in the photo. She was asked if a male nurse had worked recently at the facility. The UM responded that there had been none, but that there was an agency nurse that had worked the first of April and described them self as transgender stating they were transitioning from a male to female. She felt that it was unusual that the nurse stated this as she had not brought it up as a question. She stated she sat with the person and imported the information into the facility's computer system so that they could work that shift. The Director of Nursing (DON) approached and asked what was taking place. She was informed that we were discussing a question about agency staff. She was asked if there was a male nurse or transgender agency nurse that had recently worked at the facility, and she confirmed that there was someone the first of April. The Unit Manager and the DON were asked if they could describe this person. They looked at this writer (who is 5'11) and stated that the person who worked was a little shorter than you and a medium built black person. When asked if the identification of the agency person is checked and that their documents, licensure and level II background screen, are valid, the DON responded that they rely on the agency they contract with to do this. The DON made a remark stating, The staff were asking if the person is a male or female. During an interview on 4/13/2022 at approximately 12:30 PM with the Administrator, a request was made for documentation signed by Staff A. The Administrator provided documentation. The signature signed by Staff A was compared to the signed signature on Staff A's driver's license on record with the facility. The Administrator stated, They don't match while reviewing the signatures. During an interview on 04/15/2022 at 10:20 AM with the Medical Director, when asked the expectations for agency staff who present to the facility, she stated, To make sure and ensure the safety and security of the patients, they should hire more permanent staff, they should have a process to check for agency staffs' identification. The facility must have a staff retention plan in place, match the employee's salary with other facilities, and make sure to check agency staffs' identification. During an interview on 04/15/2022 at approximately 10:45 AM via telephone with Staff E, Registered Nurse (RN), when asked if she worked with a person by the name of [Staff A's name] on 03/31/22 to 04/01/2022, she stated, Yes, he was about my height, I'm 5'8, he had twisted hair. I'm sure it's called something else but twisted is what I call it. The reason I remember it so well is because he had signed out an antibiotic but hadn't administered it. I asked him about it, and he seemed very nervous. So, I asked him again as I needed to give it to the resident, but I didn't want to do that if he had actually given it. He said no, I didn't give it. I don't remember his name. It was something like [similar names voiced], but not [first name of Staff A], I really don't recall. Review of the Interview Record Form dated 04/12/2022 documented: Date of Event 3/31/22 - 4/1/22, [Staff B's name], RN, employee, Statement written by: individual. On the evening of 03/31/2022 - agency nurse came to Unit Manager office stating that they needed to be put in the system. Agency nurse told me that they were transgender. Introduced herself as [female name] but the name [Staff A's name] is on the nursing license. Provided nursing license number. I put nurse in the PCC [point click care] system and checked with her before I left. I noted she was pleasant with our customers. Was not having any issues with PCC. Review of the Interview Record Form, dated 4/14/22, documented: Date of Event 3/31/22, Name of Person Supplying Statement: [Staff C's name], LPN [Licensed Practical Nurse], Statement being made by: Employee. Describe the circumstances of the event/incident (Who, What, Where, When and Why). On 3/31/22 at 3:15 PM, I was relieved by an agency nurse who introduced them self to me and stated, Hi, I'm [female name] and I'm a transgender. Due to this nurse (agency nurse) wearing a mask, I was unable to determine if this was a male or female nurse and if there was any facial hair noted beneath the mask. Review of the Team Member Interview/Statement Form dated 4/13/22, documented: Team Member Name/Title: [the DON's name] RN DON. Describe in detail what occurred? (Only first hand observations, not what he/she was told by someone else. If team member has no knowledge of incident that should be [not legible] documented. On 3/31/2022 I needed to give [Staff A's name] agency nurse assigned to 2 east some information. This nurse was of average height, race black. I was unable to determine if they were male or female from distance. They were I approached them as they were at the med cart noted a masculine appearance, they had a mask on per facility protocol. Their hair was in corn rows/braids. I spoke with them briefly and they stated thank you. Review of the Interview Record Form dated 04/13/22, documented: Date of Event 3/31 - 4/1/22, Name of Person Supplying Statement: [Staff D's name], LPN. On 4/1/22, as I arrived to the elevator, I observed a black male with facial hair sitting at the nursing station. He had made statements to the fact he was waiting for his relief nurse. The oncoming nurse that was assigned to take his cart had told me, that he had introduced himself as [female name] and he was a transgender. Review of the Controlled Medications Shift Accountability Record Nurse's Signature dated 3/31 for the 3-11 shift and for 3/31 the 11-7 shift documented the signature for Staff A. Review of the staffing agency documentation for Staff A, Staff A signed multiple employment forms to include a W4, I-9, Life Line Training Resources - CPR certification, ACHA (Agency for Health Care Administration) Affidavit of Compliance, etc. revealed the signatures provided on these and several other documents do not match the signature provided on the Controlled Medications Shift Accountability Record provided by the facility. Review of staffing for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:45 AM documented Staff A worked in the facility over this period of time and was assigned to provide skilled nursing services for 27 residents residing on the memory care/dementia secured unit. Dated 03/31/2022 at 2:45 PM the facility documented one third party contracted nurse and four certified nursing assistants. Dated 03/31/2022 at 10:45 PM the facility documented one third party contracted nurse and two CNAs. Review of the medical records for a sample of residents residing on the memory/dementia secured unit documented: Resident #4 was admitted into the facility on [DATE] with diagnosis of: Alzheimer's Disease [a type of dementia that affects memory, thinking and behavior], dementia, type II diabetes [impairment in the way the body regulates and uses sugar as fuel; if a diabetic's blood sugar is dangerously low it can lead to a diabetic coma. If a diabetic's blood sugar is dangerously high it can lead to coma and/or ketoacidosis, a life-threatening event when the body does not have enough insulin], hypertension [high blood pressure requiring knowledge and education of the safe blood pressure range], need for assistance with personal care, anxiety disorder [a mental health condition], long term use of insulin, dry eye syndrome, major depressive disorder [feeling of sadness and loss of interest], history of falling, restlessness and agitation, anorexia [lack or loss of appetite for food], psychotic disorder with delusions [serious mental illness in which a person cannot tell what is real from what is imagined], mixed hyperlipidemia [your blood has too many fats such as cholesterol and triglycerides]. Review of the medication administration record and the treatment administration record for Resident #4 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #4 as follows: 3/31/2022 at 4:00 PM: Docusate Sodium Tablet, Losartan Potassium [used to treat high blood pressure], Metoprolol Tartrate [used to treat high blood pressure], Trazodone HCL [used to treat depression, decrease anxiety and insomnia]. 3/31/2022 at 5:00 PM: MedPass [supplement]. 3/31/2022 at 6:00 PM Atorvastatin Calcium Tablet [used to lower bad cholesterol]. 3/31/2022 at 8:00 PM Levemir Flex Touch Solution Pen by injection [used to control high blood sugar in people with diabetes, if the blood sugar becomes dangerous low it can lead to coma, if the blood sugar is dangerously high it can lead to coma and/or ketoacidosis, a life-threatening event. If insulin is not injected into the subcutaneous tissue, it can be absorbed too quickly into the body and can lead to a low blood sugar level], Acetaminophen [pain], Accucheck to determine the blood glucose level 122 [requires education and knowledge on how to complete an accucheck and safe blood sugar result ranges]. 3/31/2022 at evening: OcuSoft Eyelid Cleansing Pad, topical. 3/31/2022 at 3-11 shift: House fungal cream to under left breast every evening shift for redness. 3/31/2022 at eve & night: Aquaphor to bilateral upper & lower extremities every shift for skin integrity. 3/31/2022 at eve & night: check for placement of adult monitoring devices. 3/31/2022 at eve & night: Skin prep to elbows, hips, coccyx and heels for preventative skin care. 4/01/2022 at 6:00 AM: Accucheck 112. Review of the medical record for Resident #14 documented the resident was admitted into the facility 03/20/2021 with diagnosis to include: type II diabetes, dementia, chronic obstructive pulmonary disease [a chronic inflammatory lung disease that causes obstructed airflow from the lungs, fibromyalgia [a condition that causes pain all over the body], cardiac arrhythmia [an irregular heartbeat], essential hypertension, major depressive disorder, long term use of insulin, adjustment disorder with depressed mood [feelings of sadness, hopelessness, crying and lack of joy from previous pleasurable things], syncope and collapse [a temporary loss of consciousness usually related to insufficient blood flow to the brain], disorientation [confused about the time, where you are or even who you are], restless leg syndrome [an uncontrollable urge to move the legs], history of transient ischemic attack [a temporary period of symptoms similar to those of a stroke, often called a mini stroke], unspecific psychosis [used if there is inadequate information to make the diagnosis of a specific psychotic disorder], esophageal reflux [the sphincter muscle at the lower end of your esophagus relaxes at the wrong time, allowing stomach acid to back up into your esophagus], atherosclerotic heart disease [a buildup of fats, cholesterol and other substances in and on your artery walls]. Review of the medication administration record and the treatment administration record for Resident #14 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #14 as follows: 03/31/2022 at 4:00 PM Cholecalciferol [supplement to treat a vitamin D deficiency], Cyanocobalamin [vitamin B12], Amlodipine [lowers blood pressure], Apixaban [blood thinner requiring knowledge of the use of the medication and assessment for bleeding], Metformin HCL [used to control high blood sugar], Depakote Sprinkles Capsule Sprinkle [treats symptoms of mania, epilepsy, and migraine prophylaxis]. 03/31/2022 at 4:30 PM Accucheck. 03/31/2022 at 8:00 PM Atorvastatin Calcium, Donepezil HCL [used to treat Alzheimer's disease], Docusate Sodium [used to treat constipation], Accucheck. 03/31/2022 Evening and Night shifts - No sting skin-prep to hip, elbow, heel, coccyx topically. 3-11 shift- Behavior assessment. 11-7 shift- Behavior assessment. 04/01/2022 at 6:30 AM Accucheck: 167, Lantus Solution by injection [long lasting insulin used to treat high blood sugar]. If insulin is not injected into the subcutaneous tissue, it can be absorbed too quickly into the body and can lead to a low blood sugar level. Review of the medical record for Resident #32 documented the resident was admitted into the facility 10/01/2021 with diagnosis to include: chronic kidney disease stage 3 [mild to moderate damage to the kidneys and they are less able to filter waste and fluid out of your blood], Alzheimer's Disease, dementia, major depressive disorder, anxiety disorder, esophageal reflux, atherosclerotic heart disease, constipation, other idiopathic peripheral autonomic neuropathy [damage of the peripheral nerves where cause cannot be determined]. Review of the medication administration record and the treatment administration record for Resident #32 for the period of 03/31/2022 beginning at 2:45 PM through 04/01/2022 ending at 7:15 AM documented Staff A administered and/or provided treatments for Resident #32 as follows: 03/31/2022 at 4:00 PM Vitamin B-12, Vitamin D3. 03/31/2022 at 5:00 PM Xanax [used to treat anxiety and panic disorders]. 03/31/2022 Evening assessed for anxiety, insomnia documenting - Yes Insomnia observed, Staff A documented the resident verbalization of sad feeling/crying - Yes [there was no documentation the physician was notified of these findings]. 03/31/2022 at 8:00 PM Donepezil HCL, Gabapentin [anticonvulsant to treat seizures, off label use for neuropathy] Trazodone HCL. 04/01/2022 Night assessed for anxiety, insomnia documenting yes, insomnia observed. Night assessed and documented verbalization of sad feeling/crying - Yes [there was no documentation the physician was notified of the findings]. 03/31/2022 to 04/01/2022 Evening and Night assessed for the placement of adult monitoring device. 04/01/2022 at 6:00 AM Omeprazole [used to decrease the amount of acid in the stomach]. Review of the TERMS OF USE & MASTER STAFFING AGREEMENT by and between the third party contracted staffing agency and the facility [Client] dated March 2, 2022, as the effective date reads: 1. Staffing Services. 1.2. All HCPs [Health Care Providers] shall be independent contractors of Agency. No HCPs will be employees of Agency. 3. Client's Responsibilities. 3.1. Requesting HCPs. 3.1.1. Client will utilize Agency's web portal [web portal provided] to access Agency's supplemental staffing services and electronic timesheet system. Agency utilizes [web portal name] and electronic mail to communicate with Client the creation, cancelation, and assignment of HCPs along with application documentation for that HCP. It is Client's sole responsibility to maintain accurate designated recipients of email communication. 3.3. Monitoring HCP's. 3.3.1. Client shall provide orientation which, at minimum, includes the review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA, and EMR/Charting where applicable. HCP shall report too Client 30 minutes prior to the first scheduled shift for such orientation. 3.3.3. Client shall provide HCP all necessary equipment and software needed to perform Client's required duties. HCP will be required to follow all Client's procedures and protection protocols. IT is the sole responsibility of the Client to monitor and enforce all policies and procedures with HCP. Agency will assume no liability for any equipment, software, policies or enforcement measures provided to HCP. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Ad Hoc QAPI [Quality Assurance Performance Improvement] held with the leadership team to include the Medical Director on 4/12/22. Skin check audits for the 27 resident residing in the memory care unit were completed, the psychosocial status for abuse and neglect of the residents was conducted by Social Services, interviews were completed with the resident's representatives, the medication administration records were audited, narcotic count sheets were audited, audits for identification, licensure/certification, and level II background screenings were completed for all agency staff, 112 of 112 staff signed attending training on abuse/neglect/exploitation, and verification of agency staff, the Administrator and Director of Nursing received training from the Regional Team and provided training to the Assistant Director of Nursing, Social Services, and Unit Managers regarding abuse/neglect and identification verification for third party contracted staff. Interviews were conducted with the Administrator, the Director or Nursing, and the Assistant Director of Nursing to verify the training completed. Interviews were conducted with sampled seven facility and third party contracted staff to include four nurses and three certified nursing assistants regarding training in abuse, neglect, and third party contracted staff identity verification to complete verification of licensure/certification and level II background screens, and observations were conducted of third party contracted staff being identified and verified prior to access to residents.