**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility 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 prior to employment as a licensed practical nurse providing care and services for 17 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #39, #10, #7, #29, and #66. The failure of ensuring an individual is licensed as a practical 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, suctioning of a tracheostomy [trach] without training can predispose the resident to bradycardia (slow heart rate) and hypoxia (a state in which oxygen is not available in sufficient amounts), 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 include: Review of Staff A's personnel file documented an application for employment dated 12/29/2022. The application had two social security numbers and two dates of birth documented. The application listed two work experience references and three personal/professional references. The file did not provide documentation of the verification of prior employment or for the personal/professional references. The College, Business School, Military (most recent first) documented Staff A completed General Studies/Nursing [year documented], with the birth date provided at the time of interview the applicant would have been [AGE] years of age when the course of study was completed. Staff A's Level II background screening had a different spelling of the first name on the employment application, social security card, and the driver license on record. The nursing license on file provided a different spelling of the first name, had a middle name, a single last name, a different address, the address on the application, driver license, and Level II background were from a different state. The nursing license was originally issued in 2014 in the state of Florida, the driver license on record was issued in 2020 in the state of Georgia. The Basic Life Support card on file has a different last name. The file did not contain a practical nursing license for the person named on the application. The nursing license on record was not made a part of the record until 5/1/2023 at 11:02 AM as verified by the date and time printed on the document, and not at the time of hire. 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 Practical Nurse in the State of Florida. Review of Staff A's time clock punch in and out documented Staff A worked 17 shifts in the facility for the period of 2/3/2023 through 4/25/2023. Review of the admission record for Resident #39 documented the resident was admitted on [DATE] with diagnosis to include acute respiratory failure (a life-threatening disease where the air sacs in the lungs cannot release oxygen into the blood), gastrointestinal hemorrhage (gastrointestinal bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit, but isn't always visible, the level of bleeding can range from mild to severe and can be life-threatening), sepsis (a life threatening response by the body to infection that can lead to tissue damage, organ failure and death), anemia, type 2 diabetes mellitus, severe protein calorie malnutrition, paroxysmal atrial fibrillation (an irregular heart beat), gastroesophageal reflux disease, cognitive communication deficit, aphasia (the inability to speak), status tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help a person breath), status gastrostomy (a tube inserted into the stomach to provide nutrition). Review of the Medication Administration Record (MAR) for Resident #39 dated 2/4/2023, 4/7/2023, 4/8/2023, 4/15/2023, 4/18/2023 documented Staff A completed a check of Resident #39's temperature, oxygen saturation to include trach orders for monitoring oxygen saturation, observed for signs and symptoms of COVID-19 virus, evaluated the resident's pain level, flushed Resident #39's enteral tube/g-tube with 60 ml of water flush, checked the stomach residual via g-tube, started enteral tube feeding of Osmolite, and documented the total amount of enteral feeding administered. Dated: 2/5/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023, Staff A completed fingerstick for blood sugars. Dated 4/4/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023 Staff A administered ipratropium-albuterol inhalation solution via trach, levetiracetam via g-tube, metoprolol tartrate via g-tube, rosuvastatin calcium via g-tube, gabapentin, insulin detemir 58 units subcutaneously (an injection made below the dermis and epidermis, not into the muscle). Dated 2/4/2023 Staff A administered guaifenesin via g-tube. Review of the Treatment Administration Record (TAR) dated 2/4/2023 Staff A documented applying skin prep to Resident #39's bilateral heels, performed suctioning to the resident's tracheostomy, provided trach care, verified trach (tracheostomy) oxygen at 2 liters per minute, applied barrier cream to the resident's coccyx, applied dexamethasone dipropionate external cream to the resident's chest and arms, documented the head of the bed at 30-45 degrees, and provided ostomy care. Review of the admission record for Resident #10 documented the resident was admitted on [DATE] with diagnosis to include chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus, major depressive disorder, atherosclerotic heart disease, hypertension, insomnia, bradycardia (heart rate that is too slow), restless legs syndrome, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation), hypothyroidism, heart failure (severe failure of the heart to function properly, especially as a cause of death), gastro-esophageal reflux disease, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), history of infectious and parasitic diseases, difficulty walking, and orchitis. Review of the MAR for Resident #10 dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A administered Basaglar KwikPen insulin glargine 50 units subcutaneously, Eliquis (a medication that can cause bleeding, which can be serious), Flomax, Lipitor, ropinirole HCL, trazodone HCL, Oscal, clonidine HCL, hydralazine HCL, and Tylenol. Dated 3/9/2023 Staff A administered hydralazine. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered levothyroxine sodium. Dated 4/15/2023 and 4/16/2023 Staff A administered Debrox Otic Solution in both ears. Dated 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered clonidine HCL and hydralazine HCL. Dated 3/08/2023, 3/17/2023, 4/15/2023, 4/17/2023, and 4/18/2023 Staff A applied a Pain Relief Maximum Strength 4% Patch transdermally (absorbed through the skin) for pain. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #10 dated 3/08/2023, 3/17/2023, 4/15/2023, and 4/18/2023 Staff A obtained the resident's temperature, oxygen saturation, and evaluated the pain level. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023 4/19/2023 and 4/20/2023 Staff A perform accuchecks (to measure glucose/sugar in the veins whole blood). Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023 and 4/19/2023 Staff A monitored for signs and symptoms of bleeding. Review of the admission record for Resident #7 the resident was readmitted on [DATE], with an initial admission date of 5/5/2022 with diagnosis to include metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), end stage renal disease (the kidneys cease functioning), dependence on renal dialysis (when you have kidney failure, the kidneys do not filter blood the way they should. The result is waste, and toxins build up in the bloodstream. Dialysis does the work of the kidneys removing the waste products and excess fluid from the blood) , acute kidney failure, type 2 diabetes mellitus with hyperglycemia (high blood sugar), morbid severe obesity, acquired absence of right leg below the knee, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease (a slow and progressive circulation disorder), essential primary hypertension, atrial fibrillation, lymphedema (swelling due to build-up of lymph fluid in the body), and acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). Review of the MAR for Resident #7 dated 3/7/2023, 3/17/2023 Staff A administered atorvastatin calcium, melatonin, simethicone, decubi-vite, metoprolol tartrate, Novolin 70/30 insulin 19 units subcutaneously, Flomax. Dated 3/16/2023, 3/18/2023 Staff A administered simethicone. Dated 4/15/2023, 4/18/2023, 4/19/2023 Staff A administered tamsulosin, simethicone, metoprolol tartrate, flecainide acetate, atorvastatin calcium, melatonin, nephron-vite, ferrous sulfate, aspirin. Dated 4/8/2023, 4/16/2023, 4/17/2023, and 4/18/2023 Staff A administered hydralazine HCL. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #7 dated 4/16/2023, 4/19/2023, 4/20/2023 documented Staff A observed the resident for cough and deep breathing exercises for 5 minutes. Dated 4/15/2023 and 4/19/2023 Staff A observed the resident for signs and symptoms of COVID-19. Dated 3/7/2023, 3/16/2023, 3/17/2023, 3/18/2023, 4/15/2023 Staff A obtained the resident's temperature and oxygen saturation. Dated 4/15/2023, 4/16/2023, 4/18/2023, 4/19/2023, and 4/20/2023 Staff A performed a finger stick for blood glucose. Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A evaluated the resident's pain level. Dated 3/13/2023, 3/9/2023, 3/16/2023, 3/17/2023, and 3/18/2023 Staff A performed accuchecks. Review of the admission record for Resident #29 documented the resident was admitted on [DATE] with diagnosis to include acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), sepsis, urinary tract infection, dysphagia (swallowing difficulties), hydronephrosis with renal and ureteral calculus obstruction (dilatation and distension of the renal collecting system of one or both kidneys due to obstruction of urine outflow distal to the renal pelvis), polyneuropathy, anxiety disorder, anemia, hypothyroidism, hyperlipidemia, severe protein calorie malnutrition, depression, seizures, essential primary hypertension, acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral, unspecified asthma, acute respiratory failure with hypoxia, osteoarthritis, obstructive and reflux uropathy, chronic kidney disease stage 4, personal history of malignant neoplasm of uterus, personal history of COVID-19 and status gastrostomy. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023, and 3/30/2023 documented Staff A administered atorvastatin. Dated 3/23/2023, 3/24/2023, and 3/29/2023 administered levothyroxine via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/7/2023 and 4/8/2023 Staff A administered atorvastatin via g-tube. Dated 4/8/2023 and 4/9/2023 administered levothyroxine sodium via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/24/2023 and 4/25/2023 administered sodium bicarbonate via g-tube. Dated 4/25/2023 administered Lipitor via g-tube, metoprolol tartrate via g-tube, Remeron via g-tube, and Vimpat via g-tube. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023 and 3/30/2023 documented Staff A assessed for enteral feed residuals, administered enteral feeding via g-tube. Dated 3/22/2023, 3/23/2023, 3/28/2023 and 3/30/2023 Staff A administered enteral feeding via g-tube, flushed the enteral feeding tube every hour with 10 ml of water, flushed the enteral feeding tube with 50 ml of water before and after medications and feedings, documented the enteral feeding intake, evaluated the resident's pain level, observed the resident for signs and symptoms of COVID-19, and obtained the resident's temperature and oxygen saturation. Dated 4/7/2023 and 4/8/2023 evaluated the resident's pain level, obtained the resident's temperature and oxygen saturation, observed for signs and symptoms of COVID-19, obtained the resident's temperature and oxygen saturation, documented the enteral feeding intake, assessed the enteral feeding residual, administered enteral feeding of Osmolite, flushed the enteral feeding tube with 10 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings. Dated 4/24/2023 observed for signs and symptoms of COVID-19, administered enteral feeding of Isosource at 60 ml per hour x 24 hours and documented enteral feeding of Osmolite at 60 cc [cubic centimeters] per hour, assessed enteral feeding residuals, flushed the enteral feeding tube with 45 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings, evaluated the resident's pain, documented the enteral feeding intake Dated 4/25/2023 Staff A documented cough and deep breathing exercises for 5 minutes, documented the enteral feeding intake, and evaluated the resident's pain level. Review of the TAR for Resident #29 dated 4/7/2023 and 4/24/2023 Staff A documented repositioning the resident every 2 hours. Dated 4/7/2023 Staff A provided wound care to the resident's coccyx. Dated 4/7/2023, 4/24/2023 Staff A documented checking the nephrostomy (a catheter/tube that drains urine from the kidneys) insertion site for signs and symptoms of infection or bleeding to the site to the right back and left back, check the head of bed up at 30-45 degrees. Dated 4/7/2023 Staff A checked for patency of the resident's indwelling Foley catheter, checked the leg anchor for the resident's indwelling Foley catheter, ensured the specialty air mattress was functioning properly and was at the proper setting. Dated 4/24/2023 checked the leg anchor for the resident's indwelling Foley catheter, monitored the resident's bowel sounds, Staff A administered an enema to Resident #66. Review of the admission record for Resident #66 documented the resident was admitted on [DATE] with diagnosis to include gastritis, diaphragmatic hernia, toxic encephalopathy (brain dysfunction caused by toxic exposure), acute respiratory failure, epilepsy (a brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions associated with abnormal electrical activity in the brain), anemia, aortic arch syndrome (structural problems in the arteries that branch off of the aortic arch), dysphagia, unspecified glaucoma, hypothyroidism, type 2 diabetes mellitus, hypertension, diastolic congestive heart failure (occurs if the left ventricle muscle becomes stiff or thickened), paralysis of vocal cords and larynx bilaterally (hoarseness and abduction of the vocal cords increasing aspiration risk), cognitive communication deficit, personal history of benign neoplasm of the brain (a mass of cells that grow slowly in the brain), personal history of COVID-19, personal history of traumatic brain injury, status tracheostomy, status gastrostomy. Review of the MAR for Resident #66 dated 4/19/2023 and 4/20/2023 documented Staff A administered oxcarbazepine via g-tub, lisinopril via g-tube, vitamin D3 via g-tube, Coreg via g-tube, Depakene via g-tube, atorvastatin calcium via g-tube, Keppra via g-tube, lacosamide via g-tube, magnesium oxide via g-tube, phenobarbital via g-tube, potassium chloride via g-tube, sennosides-docusate via g-tube, and zegerid via g-tube. Review of the MAR dated 4/18/2023 and 4/19/2023 documented Staff A evaluated Resident #66 for pain level, monitored the resident's trach oxygen saturation, observed the resident for signs and symptoms of COVID-19, assessed for enteral feed residuals, flushed the enteral feed tube with 50 ml of water before and after medications/feedings, flushed the enteral feed tube every hour with 70 ml of water, documented the enteral feed total intake. Dated 4/19/2023 and 4/20/2023 Staff A performed finger sticks for blood glucose. Dated 4/18/2023 Staff A evaluated the resident's temperature and oxygen saturation. Review of the TAR for the dates of 4/18/2023 through 4/19/2023 when Staff A was the attending staff person for Resident #66 there is no documentation dated 4/18/2023 of the resident having been provided trach care to verify the equipment was plugged into a red socket, the oxygen settings, humidification, and bottle storage. Dated 4/19/2023 there is no documentation the resident was provided trach care to include removing the non-disposable inner cannula and cleaning, verification of the trach oxygen at 7 liters with 100% humidification, scrubs to both eyes, trach suctioning, and verification the head of the bed was up to 30-45 degrees to prevent aspiration. Documentation was requested from the Director of Nursing (DON) on 5/17/2023 at 9:10 AM to verify the resident received the physician ordered care. No documentation was provided. During an interview on 5/17/2023 at 9:10 AM the DON stated, I have recently taken over this job and did not hire that employee [Staff A]. I was here when the Administrator was notified that she was being investigated by [NAME] for identity theft of a nurse and they tracked her here by her cell phone. The administrator worked with that detective and the [name of the local law enforcement agency], and she was arrested here after she clocked in for her shift. Once we learned about this, we began an investigation. She had a background screening that came back eligible and did present a driver's license and social security card. Unfortunately, her license was in a different name. I can't tell you how this happened. We did not do the proper license verification. There were not any reference checks completed and her previous employers were not contacted to determine if she had actually worked for them. I don't know how this occurred. It should not have happened. We should never have hired her with the conflicting dates of birth and with the conflicting social security numbers. I do believe that it should have been escalated when she gave those, I think probably to the human resources' responsible person and the Administrator. After that we absolutely should have verified that she had a valid nursing license and requested that she bring in a copy of her license before we allowed her to work. During an interview on 5/17/2023 at 4:18 PM Staff B, Licensed Practical Nurse (LPN) stated, I did run this persons [Staff A] AHCA (Agency for Healthcare Administration) background screen. I used to do all the background screenings and managed the roster and things like that. Once I completed those, I would give them to HR [Human Resources] and then they would hire them in the system and do their part. Well, in April of 2022, Bedrock took over. They wanted my position to be more nursing and to do infection control, so then that's when the HR started taking over the backgrounds, but there was a transition, so I would still help [Staff C's name], like showing her how to resubmit backgrounds and how to pull new backgrounds so everything was complete. I did the background on [Staff A's name] in January after that I've given information to the HR, to [Staff C's name]. Well on our applications there is not a section for an employee's date of birth or social security number. I wrote the date of birth and social security number she gave me when I talked with her a few weeks after her interview when she let me know she wanted to proceed with becoming an employee. I then tried to do her background screening and she was not in the system with the original birthdate that she gave me. I wrote the [date written] and the social security number that is on there [the employee application]. So, then I had to call her and tell her I can't find her. That is when she told me that someone had stolen her identity and the government issued her new cards and a new birthdate. She then gave me a new birthdate and social security number. It was a different birthdate of [birth date given] and a new social security number. Once I put in the new information on the background screening, she came back as eligible, and it was the same person that I interviewed. I didn't think a thing, I have had others give me the wrong social security number so, I didn't think to escalate this to anyone else in HR. I did not tell [Staff C's name] about it. It did not concern me at all. I'm not a criminal so I believed her. Her background screening per AHCA came back eligible. I didn't question it all. I mean people mix up things, but when I put in her last name with that social her picture pulled up the social matched the date of birth on there and matched her picture that was on there, everything matched with the second date of birth . I did not bring any concerns about this to [Staff C's name], she cleared and was eligible. I did her interview. I do have the application in front of me when I interview. I didn't look at her education and ask her any questions about that. We just talked about her experiences, if she had taken [care of] trachs, her general experiences, if she was comfortable with g-tubes and medications. I didn't look at how her name was spelled and see that it was not the correct spelling. She did tell me that she got divorced and that's why there was a different name and that she had her identity stolen. I don't know how the license verification was done. The day that this was all being investigated we found out that the license verification wasn't in her file. I guess that's when she [Staff C's name] did it. I don't know when or if she did it when she [Staff A's name] was hired. I'm not HR. During a telephone interview on 5/19/2023 at 9:20 AM the previous Nursing Home Administrator stated, I was notified on I believe it was 4/24 or 4/25/23 by a detective in [NAME] that they believed they had tracked a nurse with a fraudulent nursing license, and they were working in our building. I verified his identity and began to assist him in any way I could. Looking back at our files we determined that she [Staff A] gave two different social security numbers and she was called and changed her social security number and birth date. This got missed by [Staff B and Staff C's names]. I was not aware that the nursing license was not in the file and that she did not provide a copy of the nursing license. I would say the HR Manager should have caught this and brought it to the attention of someone when she gave multiple birthdays and social security numbers, that would be an immediate red flag. It should come to corporate HR and the Administrator. [Staff B's name] was well aware of the changing date of birth and social security number. At some point they both knew and should have responded, and we should not have hired her [Staff A]. We, upon investigation, suspended [Staff C's name] because she was in the role and had the responsibility to make sure that all aspects of the employment process is fully implemented and followed. Ultimately, administrators are responsible for the overall running of the building and all disciplines. This [Staff C's name] had been in HR since about last August or September, there is some debate on the amount of training she received, and she was learning on the fly. The mistake was made because they were not properly trained and did not understand the severity of the situation when [Staff B's name] was provided with two different birthdates and social security numbers. [Staff C's name] was in that role less than one year and they were trying to combine the role she had previously been in with HR responsibilities and make [Staff B's name] role more nursing. They put themselves [Bedrock] in this position by inadequately training [Staff C's name] to fulfill her role. During a telephone interview on 5/19/2023 at 3:30 PM the Medical Director stated, I was notified immediately on Friday night that there was a nurse who was fraudulent and without a license that had been practicing with the residents. She was not properly cleared to work and the system to verify her license and identification was not followed. The police arrested her [Staff A] at the facility very late on Friday and we met on Monday to do a QAPI [Quality Assurance Performance Improvement] we did conduct the root cause. The names were different, and the nursing license was not verified. Luckily nothing happened to any of my residents nor other physicians' residents. It is imperative that we verify these things and have these systems in place, they promote and protect patients. They ensure that we provide a minimum standard of care that non licensed nurses cannot provide. There was great potential for harm if she had come across a situation that she was unfamiliar with. I hope we now have the system to safeguard all the residents in place and we will keep monitoring this to make sure this never happens again. She would not have the necessary knowledge to care for a tracheostomy tube, or possibly understand what to do if the resident accidentally decannulated [removed the tracheostomy] themselves. Gastrostomy tube medication administration is more complex with possible gastric perforation if not verified as present in the correct place and would require assessment skills that nurses have. Review of the policy and procedure titled, Abuse: Florida dated 4/1/2022 read, Definitions Of Abuse and Neglect: 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. Policy: It is the policy of Bedrock care that each resident will be free from ABUSE. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. 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. Objectives 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. Our facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and or potentially abusive attitude toward the resident(s). Overview of seven components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. A. Screening Components: It is the policy of this facility to screen employees and volunteers (as applicable per volunteer policy) prior to working with residents. Screening components include verification of certification and verification of license and criminal background check. Procedure: 1. Employee Screening and Training: 1a. New employees have a background check as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. C. License Staff: The facility will not employ or otherwise engage a licensed professional who: a. Has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. b. In addition, the facility will report to the state licensing authorities any knowledge it has of the actions by a court of law against an employee which would indicate unfitness for service as a licensed professional. Review of the policy and procedure titled, Employee Personnel Records dated 4/1/2022 read, Bedrock Care maintains certain records for each employee which are directly related to his/her employment. Personnel records contain the following data: The employee's full name, address, date of birth , sex, and Social Security Number, Employment references, letters, etc., Copy of current licenses (as applicable). The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the Root Cause Analysis provided by the facility was an untitled document provided by the facility, with no date or time indicated read, Problem statement: [Staff A's name] worked in nursing home without a valid license. Why? Detective notified facility of identity theft by [Staff A's name] questioning accuracy of nursing license. Why? Level 2 AHCA clearing house background [Staff A's name] eligible for employment. Why? Forms of identification matched spelling of name identical on Social Security and driver's license. Why? No results on OIG exclusion list [Staff A's name]. Why? License verification on FDOH (Florida Department of Health) [a different nurses name] clear/active root causes:1. Identity theft. 2. Spelling of name on driver's license and nurses license not match. 3. Middle name different on level 2 and nurse license. Review of the Performance Improvement Plan dated 5/1/2023 documented [Medical Director's name] was notified of the removal of [Staff A's name] from the facility. The Staff Developer and Regional Nurse conducted a quality review of 30 licensed nurses to ensure proper identification and valid and active nursing license in their file. Completed 5/1/23 for 30 of 30 licensed nurses. No discrepancies found. Seventy-seven resident assessments were completed by the Director of Nursing on residents that were provided care and services by [Staff A's name]. No areas of concern noted. Completed 5/1/2023. Discharge resident records were reviewed by the Director of Nursing with no concern noted. C[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure policies and procedure 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 prior to employment as a licensed practical nurse providing care and services for 17 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #39, #10, #7, #29, and #66. Findings include: Review of the policy and procedure titled, Abuse: Florida dated 4/1/2022 read, Definitions Of Abuse and Neglect: 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. Policy: It is the policy of Bedrock care that each resident will be free from ABUSE. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. 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. Objectives 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. Our facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident and creates an environment that perpetuates a disrespectful and or potentially abusive attitude toward the resident(s). Overview of seven components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. A. Screening Components: It is the policy of this facility to screen employees and volunteers (as applicable per volunteer policy) prior to working with residents. Screening components include verification of certification and verification of license and criminal background check. Procedure: 1. Employee Screening and Training: 1a. New employees have a background check as appropriate board registrations and certifications regarding the prospective employee's background. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. C. License Staff: The facility will not employ or otherwise engage a licensed professional who: a. Has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. b. In addition, the facility will report to the state licensing authorities any knowledge it has of the actions by a court of law against an employee which would indicate unfitness for service as a licensed professional. Review of Staff A's personnel file documented an application for employment dated 12/29/2022. The application had two social security numbers and two dates of birth documented. The application listed two work experience references and three personal/professional references. The file did not provide documentation of the verification of prior employment or for the personal/professional references. The College, Business School, Military (most recent first) documented Staff A completed General Studies/Nursing [year documented], with the birth date provided at the time of interview the applicant would have been [AGE] years of age when the course of study was completed. Staff A's Level II background screening had a different spelling of the first name on the employment application, social security card, and the driver license on record. The nursing license on file provided for a different spelling of the first name, had a middle name, a single last name, a different address, the address on the application, driver license, and Level II background were from a different state. The nursing license was originally issued in 2014 in the state of Florida, the driver license on record was issued in 2020 in the state of Georgia. The Basic Life Support card on file has a different last name. The file did not contain a practical nursing license for the person named on the application. The nursing license on record was not made a part of the record until 5/1/2023 at 11:02 AM as verified by the date and time printed on the document, and not at the time of hire. 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 Practical Nurse in the State of Florida. Review of Staff A's time clock punch in and out documented Staff A worked 17 shifts in the facility for the period of 2/3/2023 through 4/25/2023. Review of the admission record for Resident #39 documented the resident was admitted on [DATE] with diagnosis to include acute respiratory failure (a life-threatening disease where the air sacs in the lungs cannot release oxygen into the blood), gastrointestinal hemorrhage (gastrointestinal bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit, but isn't always visible, the level of bleeding can range from mild to severe and can be life-threatening), sepsis (a life threatening response by the body to infection that can lead to tissue damage, organ failure and death), anemia, type 2 diabetes mellitus, severe protein calorie malnutrition, paroxysmal atrial fibrillation (an irregular heart beat), gastroesophageal reflux disease, cognitive communication deficit, aphasia (the inability to speak), status tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help a person breath), status gastrostomy (a tube inserted into the stomach to provide nutrition). Review of the Medication Administration Record (MAR) for Resident #39 dated 2/4/2023, 4/7/2023, 4/8/2023, 4/15/2023, 4/18/2023 documented Staff A completed a check of Resident #39's temperature, oxygen saturation to include trach orders for monitoring oxygen saturation, observed for signs and symptoms of COVID-19 virus, evaluated the resident's pain level, flushed Resident #39's enteral tube/g-tube with 60 ml of water flush, checked the stomach residual via g-tube, started enteral tube feeding of Osmolite, and documented the total amount of enteral feeding administered. Dated: 2/5/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023, Staff A completed fingerstick for blood sugars. Dated 4/4/2023, 4/8/2023, 4/9/2023, 4/16/2023, 4/19/2023, 4/20/2023 Staff A administered ipratropium-albuterol inhalation solution via trach, levetiracetam via g-tube, metoprolol tartrate via g-tube, rosuvastatin calcium via g-tube, gabapentin, insulin detemir 58 units subcutaneously (an injection made below the dermis and epidermis, not into the muscle). Dated 2/4/2023 Staff A administered guaifenesin via g-tube. Review of the Treatment Administration Record (TAR) dated 2/4/2023 Staff A documented applying skin prep to Resident #39's bilateral heels, performed suctioning to the resident's tracheostomy, provided trach care, verified trach (tracheostomy) oxygen at 2 liters per minute, applied barrier cream to the resident's coccyx, applied dexamethasone dipropionate external cream to the resident's chest and arms, documented the head of the bed at 30-45 degrees, and provided ostomy care. Review of the admission record for Resident #10 documented the resident was admitted on [DATE] with diagnosis to include chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus, major depressive disorder, atherosclerotic heart disease, hypertension, insomnia, bradycardia (heart rate that is too slow), restless legs syndrome, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation), hypothyroidism, heart failure (severe failure of the heart to function properly, especially as a cause of death), gastro-esophageal reflux disease, psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality), history of infectious and parasitic diseases, difficulty walking, and orchitis. Review of the MAR for Resident #10 dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A administered Basaglar KwikPen insulin glargine 50 units subcutaneously, Eliquis (a medication that can cause bleeding, which can be serious), Flomax, Lipitor, ropinirole HCL, trazodone HCL, Oscal, clonidine HCL, hydralazine HCL, and Tylenol. Dated 3/9/2023 Staff A administered hydralazine. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered levothyroxine sodium. Dated 4/15/2023 and 4/16/2023 Staff A administered Debrox Otic Solution in both ears. Dated 4/16/2023, 4/19/2023, and 4/20/2023 Staff A administered clonidine HCL and hydralazine HCL. Dated 3/08/2023, 3/17/2023, 4/15/2023, 4/17/2023, and 4/18/2023 Staff A applied a Pain Relief Maximum Strength 4% Patch transdermally (absorbed through the skin) for pain. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #10 dated 3/08/2023, 3/17/2023, 4/15/2023, and 4/18/2023 Staff A obtained the resident's temperature, oxygen saturation, and evaluated the pain level. Dated 3/9/2023, 3/16/2023, 3/18/2023, 4/16/2023 4/19/2023 and 4/20/2023 Staff A perform accuchecks (to measure glucose/sugar in the veins whole blood). Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023 and 4/19/2023 Staff A monitor for signs and symptoms of bleeding. Review of the admission record for Resident #7 the resident was readmitted on [DATE], with an initial admission date of 5/5/2022 with diagnosis to include metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), end stage renal disease (the kidneys cease functioning), dependence on renal dialysis (when you have kidney failure, the kidneys do not filter blood the way they should. The result is waste and toxins build up in the bloodstream. Dialysis does the work of the kidneys removing the waste products and excess fluid from the blood) , acute kidney failure, type 2 diabetes mellitus with hyperglycemia (high blood sugar), morbid severe obesity, acquired absence of right leg below the knee, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease (a slow and progressive circulation disorder), essential primary hypertension, atrial fibrillation, lymphedema (swelling due to build-up of lymph fluid in the body), and acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body). Review of the MAR for Resident #7 dated 3/7/2023, 3/17/2023 Staff A administered atorvastatin calcium, melatonin, simethicone, decubi-vite, metoprolol tartrate, Novolin 70/30 insulin 19 units subcutaneously, Flomax. Dated 3/16/2023, 3/18/2023 Staff A administered simethicone. Dated 4/15/2023, 4/18/2023, 4/19/2023 Staff A administered tamsulosin, simethicone, metoprolol tartrate, flecainide acetate, atorvastatin calcium, melatonin, nephron-vite, ferrous sulfate, aspirin. Dated 4/8/2023, 4/16/2023, 4/17/2023, and 4/18/2023 Staff A administered hydralazine HCL. All medications were administered by mouth unless otherwise indicated. Review of the MAR for Resident #7 dated 4/16/2023, 4/19/2023, 4/20/2023 documented Staff A observed the resident for cough and deep breathing exercises for 5 minutes. Dated 4/15/2023 and 4/19/2023 Staff A observed the resident for signs and symptoms of COVID-19. Dated 3/7/2023, 3/16/2023, 3/17/2023, 3/18/2023, 4/15/2023 Staff A obtained the resident's temperature and oxygen saturation. Dated 4/15/2023, 4/16/2023, 4/18/2023, 4/19/2023, and 4/20/2023 Staff A performed a finger stick for blood glucose. Dated 3/8/2023, 3/17/2023, 4/15/2023, 4/18/2023, and 4/19/2023 Staff A evaluated the resident's pain level. Dated 3/13/2023, 3/9/2023, 3/16/2023, 3/17/2023, and 3/18/2023 Staff A performed accuchecks. Review of the admission record for Resident #29 documented the resident was admitted on [DATE] with diagnosis to include acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), sepsis, urinary tract infection, dysphagia (swallowing difficulties), hydronephrosis with renal and ureteral calculus obstruction (dilatation and distension of the renal collecting system of one or both kidneys due to obstruction of urine outflow distal to the renal pelvis), polyneuropathy, anxiety disorder, anemia, hypothyroidism, hyperlipidemia, severe protein calorie malnutrition, depression, seizures, essential primary hypertension, acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral, unspecified asthma, acute respiratory failure with hypoxia, osteoarthritis, obstructive and reflux uropathy, chronic kidney disease stage 4, personal history of malignant neoplasm of uterus, personal history of COVID-19 and status gastrostomy. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023, and 3/30/2023 documented Staff A administered atorvastatin. Dated 3/23/2023, 3/24/2023, and 3/29/2023 administered levothyroxine via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/7/2023 and 4/8/2023 Staff A administered atorvastatin via g-tube. Dated 4/8/2023 and 4/9/2023 administered levothyroxine sodium via g-tube, mirtazapine via g-tube, Vimpat via g-tube. Dated 4/24/2023 and 4/25/2023 administered sodium bicarbonate via g-tube. Dated 4/25/2023 administered Lipitor via g-tube, metoprolol tartrate via g-tube, Remeron via g-tube, and Vimpat via g-tube. Review of the MAR for Resident #29 dated 3/22/2023, 3/23/2023 and 3/30/2023 Staff A assessed for enteral feed residuals, administered enteral feeding via g-tube. Dated 3/22/2023, 3/23/2023, 3/28/2023 and 3/30/2023 Staff A administered enteral feeding via g-tube, flushed the enteral feeding tube every hour with 10 ml of water, flushed the enteral feeding tube with 50 ml of water before and after medications and feedings, documented the enteral feeding intake, evaluated the resident's pain level, observed the resident for signs and symptoms of COVID-19, and obtained the resident's temperature and oxygen saturation. Dated 4/7/2023 and 4/8/2023 evaluated the resident's pain level, obtained the resident's temperature and oxygen saturation, observed for signs and symptoms of COVID-19, obtained the resident's temperature and oxygen saturation, documented the enteral feeding intake, assessed the enteral feeding residual, administered enteral feeding of Osmolite, flushed the enteral feeding tube with 10 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings. Dated 4/24/2023 observed for signs and symptoms of COVID-19, administered enteral feeding of Isosource at 60 ml per hour x 24 hours and documented enteral feeding of Osmolite at 60 cc [cubic centimeters] per hour, assessed enteral feeding residuals, flushed the enteral feeding tube with 45 ml of water every hour, flushed the enteral feeding tube with 50 ml of water before and after medications/feedings, evaluated the resident's pain, documented the enteral feeding intake Dated 4/25/2023 Staff A documented cough and deep breathing exercises for 5 minutes, documented the enteral feeding intake, and evaluated the resident's pain level. Review of the TAR for Resident #29 dated 4/7/2023 and 4/24/2023 Staff A documented repositioning the resident every 2 hours. Dated 4/7/2023 Staff A provided wound care to the resident's coccyx. Dated 4/7/2023, 4/24/2023 Staff A documented checking the nephrostomy (a catheter/tube that drains urine from the kidneys) insertion site for signs and symptoms of infection or bleeding to the site to the right back and left back, check the head of bed up at 30-45 degrees. 4/7/2023 Staff A checked for patency of the resident's indwelling Foley catheter, checked the leg anchor for the resident's indwelling Foley catheter, ensured the specialty air mattress was functioning properly and was at the proper setting. Dated 4/24/2023 checked the leg anchor for the resident's indwelling Foley catheter, monitored the resident's bowel sounds, Staff A administered an enema to Resident #66. Review of the admission record for Resident #66 documented the resident was admitted on [DATE] with diagnosis to include gastritis, diaphragmatic hernia, toxic encephalopathy (brain dysfunction caused by toxic exposure), acute respiratory failure, epilepsy (a brain disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions associated with abnormal electrical activity in the brain), anemia, aortic arch syndrome (structural problems in the arteries that branch off of the aortic arch), dysphagia, unspecified glaucoma, hypothyroidism, type 2 diabetes mellitus, hypertension, diastolic congestive heart failure (occurs if the left ventricle muscle becomes stiff or thickened), paralysis of vocal cords and larynx bilaterally (hoarseness and abduction of the vocal cords increasing aspiration risk), cognitive communication deficit, personal history of benign neoplasm of the brain (a mass of cells that grow slowly in the brain), personal history of COVID-19, personal history of traumatic brain injury, status tracheostomy, status gastrostomy. Review of the MAR for Resident #66 dated 4/19/2023 and 4/20/2023 Staff A administered oxcarbazepine via g-tub, lisinopril via g-tube, vitamin D3 via g-tube, Coreg via g-tube, Depakene via g-tube, atorvastatin calcium via g-tube, Keppra via g-tube, lacosamide via g-tube, magnesium oxide via g-tube, phenobarbital via g-tube, potassium chloride via g-tube, sennosides-docusate via g-tube, and zegerid via g-tube. Review of the MAR dated 4/18/2023 and 4/19/2023 documented Staff A evaluated Resident #66 for pain level, monitored the resident's trach oxygen saturation, observed the resident for signs and symptoms of COVID-19, assessed for enteral feed residuals, flushed the enteral feed tube with 50 ml of water before and after medications/feedings, flushed the enteral feed tube every hour with 70 ml of water, documented the enteral feed total intake. Dated 4/19/2023 and 4/20/2023 Staff A performed finger sticks for blood glucose. Dated 4/18/2023 Staff A evaluated the resident's temperature and oxygen saturation. Review of the TAR for the dates of 4/18/2023 through 4/19/2023 when Staff A was the attending staff person for Resident #66 there is no documentation dated 4/18/2023 of the resident having been provided trach care to verify the equipment was plugged into a red socket, the oxygen settings, humidification, and bottle storage. Dated 4/19/2023 there is no documentation the resident was provided trach care to include removing the non-disposable inner cannula and cleaning, verification of the trach oxygen at 7 liters with 100% humidification, scrubs to both eyes, trach suctioning, and verification the head of the bed was up to 30-45 degrees to prevent aspiration. Documentation was requested from the Director of Nursing (DON) on 5/17/2023 at 9:10 AM to verify the resident received the physician ordered care. No documentation was provided. During an interview on 5/17/2023 at 9:10 AM the DON stated, I have recently taken over this job and did not hire that employee [Staff A]. I was here when the Administrator was notified that she was being investigated by [NAME] for identity theft of a nurse and they tracked her here by her cell phone. The administrator worked with that detective and the [name of the local law enforcement agency], and she was arrested here after she clocked in for her shift. Once we learned about this, we began an investigation. She had a background screening that came back eligible and did present a driver's license and social security card. Unfortunately, her license was in a different name. I can't tell you how this happened. We did not do the proper license verification. There were not any reference checks completed and her previous employers were not contacted to determine if she had actually worked for them. I don't know how this occurred. It should not have happened. We should never have hired her with the conflicting dates of birth and with the conflicting social security numbers. I do believe that it should have been escalated when she gave those, I think probably to the human resources' responsible person and the Administrator. After that we absolutely should have verified that she had a valid nursing license and requested that she bring in a copy of her license before we allowed her to work. During an interview on 5/17/2023 at 4:18 PM Staff B, Licensed Practical Nurse (LPN) stated, I did run this persons [Staff A] AHCA (Agency for Healthcare Administration) background screen. I used to do all the background screenings and managed the roster and things like that. Once I completed those I would give them to HR [Human Resources] and then they would hire them in the system and do their part. Well, in April of 2022, Bedrock took over. They wanted my position to be more nursing and to do infection control, so then that's when the HR started taking over the backgrounds, but there was a transition, so I would still help [Staff C's name], like showing her how to resubmit backgrounds and how to pull new backgrounds so everything was complete. I did the background on [Staff A's name] in January after that I've given information to the HR, to [Staff C's name]. Well on our applications there is not a section for an employee's date of birth or social security number. I wrote the date of birth and social security number she gave me when I talked with her a few weeks after her interview when she let me know she wanted to proceed with becoming an employee. I then tried to do her background screening and she was not in the system with the original birthdate that she gave me. I wrote the [date written] and the social security number that is on there [the employee application]. So, then I had to call her and tell her I can't find her. That is when she told me that someone had stolen her identity and the government issued her new cards and a new birthdate. She then gave me a new birthdate and social security number. It was a different birthdate of [birth date given] and a new social security number. Once I put in the new information on the background screening, she came back as eligible, and it was the same person that I interviewed. I didn't think a thing, I have had others give me the wrong social security number so, I didn't think to escalate this to anyone else in HR. I did not tell [Staff C's name] about it. It did not concern me at all. I'm not a criminal so I believed her. Her background screening per AHCH came back eligible. I didn't question it all. I mean people mix up things, but when I put in her last name with that social her picture pulled up the social matched the date of birth on there and matched her picture that was on there, everything matched with the second date of birth . I did not bring any concerns about this to [Staff C's name], she cleared and was eligible. I did her interview. I do have the application in front of me when I interview. I didn't look at her education and ask her any questions about that. We just talked about her experiences, if she had taken [care of] trachs, her general experiences, if she was comfortable with g-tubes and medications. I didn't look at how her name was spelled and see that it was not the correct spelling. She did tell me that she got divorced and that's why there was a different name and that she had her identity stolen. I don't know how the license verification was done. The day that this was all being investigated we found out that the license verification wasn't in her file. I guess that's when she [Staff C] did it. I don't know when or if she did it when she [Staff A] was hired. I'm not HR. During a telephone interview on 5/19/2023 at 9:20 AM the previous Nursing Home Administrator stated, I was notified on I believe it was 4/24 or 4/25/23 by a detective in [NAME] that they believed they had tracked a nurse with a fraudulent nursing license, and they were working in our building. I verified his identity and began to assist him in any way I could. Looking back at our files we determined that she [Staff A] gave two different social security numbers and she was called and changed her social security number and birth date. This got missed by [Staff B and Staff C's names]. I was not aware that the nursing license was not in the file and that she did not provide a copy of the nursing license. I would say the HR Manager should have caught this and brought it to the attention of someone when she gave multiple birthdays and social security numbers, that would be an immediate red flag. It should come to corporate HR and the Administrator. [Staff B's name] was well aware of the changing date of birth and social security number. At some point they both knew and should have responded, and we should not have hired her [Staff A]. We, upon investigation, suspended [Staff C's name] because she was in the role and had the responsibility to make sure that all aspects of the employment process is fully implemented and followed. Ultimately, administrators are responsible for the overall running of the building and all disciplines. This [Staff C's name] had been in HR since about last August or September, there is some debate on the amount of training she received, and she was learning on the fly. The mistake was made because they were not properly trained and did not understand the severity of the situation when [Staff B's name] was provided with two different birthdates and social security numbers. [Staff C's name] was in that role less than one year and they were trying to combine the role she had previously been in with HR responsibilities and make [Staff B's name] role more nursing. They put themselves [Bedrock] in this position by inadequately training [Staff C's name] to fulfill her role. During a telephone interview on 5/19/2023 at 3:30 PM the Medical Director stated, I was notified immediately on Friday night that there was a nurse who was fraudulent and without a license that had been practicing with the residents. She was not properly cleared to work and the system to verify her license and identification was not followed. The police arrested her [Staff A] at the facility very late on Friday and we met on Monday to do a QAPI [Quality Assurance Performance Improvement] we did conduct the root cause. The names were different, and the nursing license was not verified. Luckily nothing happened to any of my residents nor other physicians' residents. It is imperative that we verify these things and have these systems in place, they promote and protect patients. They ensure that we provide a minimum standard of care that non licensed nurses cannot provide. There was great potential for harm if she had come across a situation that she was unfamiliar with. I hope we now have the system to safeguard all the residents in place and we will keep monitoring this to make sure this never happens again. She would not have the necessary knowledge to care for a tracheostomy tube, or possibly understand what to do if the resident accidentally decannulated [removed the tracheostomy] themselves. Gastrostomy tube medication administration is more complex with possible gastric perforation if not verified as present in the correct place and would require assessment skills that nurses have. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the Root Cause Analysis provided by the facility was an untitled document provided by the facility, with no date or time indicated read, Problem statement: [Staff A's name] worked in nursing home without a valid license. Why? Detective notified facility of identity theft by [Staff A's name] questioning accuracy of nursing license. Why? Level 2 AHCA clearing house background [Staff A's name] eligible for employment. Why? Forms of identification matched spelling of name identical on Social Security and driver's license. Why? No results on OIG exclusion list [Staff A's name]. Why? License verification on FDOH (Florida Department of Health) [a different nurses name] clear/active root causes:1. Identity theft. 2. Spelling of name on driver's license and nurses license not match. 3. Middle name different on level 2 and nurse license. Review of the Performance Improvement Plan dated 5/1/2023 documented [Medical Director's name] was notified of the removal of [Staff A's name] from the facility. The staff Developer and Regional Nurse conducted a quality review of 30 licensed nurses to ensure proper identification and valid and active nursing license in their file. Completed 5/1/23 for 30 of 30 licensed nurses. No discrepancies found. Seventy-seven resident assessments were completed by the Director of Nursing on residents that were provided care and services by [Staff A's name]. No areas of concern noted. Completed 5/1/2023. Discharge resident records were reviewed by the Director of nursing with no concern noted. Completed 5/1/2023. Medication Administration Records, Treatment Administration Records and narcotic sheets were reviewed by the Director of Nursing with no concern noted. Completed 5/1/2023. Grievances were reviewed by the Director of Nursing and no concerns with [Staff A's name] noted. Completed 5/1/2023. Education: The DON, Administrator, Human Resource Director and the Staff Developer were educated by the Staff Developer on Policy/Procedure: Employee Personnel Records to include the Employee's full name, address, date of birth , Social Security Number, job application, job description, orientation and training program records, performance evaluations and employment references; Policy/Procedure: New Hire Checklist; OIG Exclusion; AHCA Clearinghouse Roster; Verifying Active and Valid Nursing License; including the Original Nursing License and the Verified Active License placed in the Employee File. Completed 5/1/2023. Bedrock Rehabilitation and Nursing Center at Suwannee currently has 30 Licensed Nursing Staff. Current Licensed Nursing Staff received education by the Staff Developer and education was completed on 5/1/2023. Education included for Licensed Nursing Staff Policy/Procedure: Abuse/Neglect; Policy/Procedure: License Verification/proper acceptable identification. Completed 5/1/2023. One hundred sixty seven of 167 total employees received education by the Staff Developer on abuse and neglect. Completed 5/1/2023. Bedrock Rehabilitation and Nursing Center at Suwannee implemented a new hire checklist to ensure proper identification documentation is collected prior to employment. Completed 5/1/2023. On 5/1/2023, harm no longer existed for the residents of Bedrock Rehabilitation and Nursing Center at Suwannee. Actions to prevent further deficient practice r/t licensed nurse identification discrepancy began on 5/1/2023 are as follows: Newly hired Licensed Nurses will receive education in orientation, as stated above. The new hire checklist will be completed by the Human Resource Director with every newly hired Licensed Nurse to include ve[TRUNCATED]

**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 implement policies and procedures to verify the identity, credentials and licensure of an individual prior to employment as a licensed practical nurse providing care and services for 17 shifts for 77 residents using a sample of 5 of 5 residents of the total 77 residents, Residents #39, #10, #7, #29, and #66. Findings include: Review of Staff A's personnel file documented an application for employment dated [DATE]. The application had two social security numbers and two dates of birth documented. The application listed two work experience references and three personal/professional references. The file did not provide documentation of the verification of prior employment or for the personal/professional references. The College, Business School, Military (most recent first) documented Staff A completed General Studies/Nursing [year documented], with the birth date provided at the time of interview the applicant would have been [AGE] years of age when the course of study was completed. Staff A's Level II background screening had a different spelling of the first name on the employment application, social security card, and the driver license on record. The nursing license on file provided for a different spelling of the first name, had a middle name, a single last name, a different address, the address on the application, driver license, and Level II background were from a different state. The nursing license was originally issued in 2014 in the state of Florida, the driver license on record was issued in 2020 in the state of Georgia. The Basic Life Support card on file has a different last name. The file did not contain a practical nursing license for the person named on the application. The nursing license on record was not made a part of the record until [DATE] at 11:02 AM as verified by the date and time printed on the document, and not at the time of hire. 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 Practical Nurse in the State of Florida. Review of Staff A's time clock punch in and out documented Staff A worked 17 shifts in the facility for the period of [DATE] through [DATE]. Review of the job description titled, Licensed Practical Nurse read, Education/Work Experience Requirements: Education: Graduate of accredited school of nursing. Certificate/Licenses: Current, active license as Licensed Practical Nurse in state of employment. Work Experience: One year experience providing direct care to residents in long term care setting preferred. Review of the job description titled, Nursing Home Administrator read, Reports to Regional Director of Operations. Job Description: The Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility, and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees and the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. Collaborates with consultants, contractors, referring physicians, community resources, government agencies and advocacy groups. Implements operational and financial objectives of management and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental, and psycho-social well-being of each resident. Specialized Knowledge & Skills: To perform the job successfully, an individual should demonstrate the following competencies: Current knowledge of state and federal laws governing the operation of nursing facilities. Knowledge of licensing and payment programs, general business practices, nursing practice, psychology of resident care, personal care and social services, therapeutic and supportive long-term care and services, and environmental health and safety relevant to nursing facility operations. Knowledge of state personnel licensing and registration requirements. Knowledge of human resource principles, labor laws and union contracts, were applicable, to manage personnel functions and to supervise Department Heads in personnel matters. Able to apply facility personnel policies to facts regarding employment actions without regard to race, religion, age, national origin, sex, or disability. Able to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Ability to foster interdisciplinary cooperation and coordination of quality assurance and quality improvement efforts. Able to develop and implement administrative policies and procedures that reflect the facility philosophy and mission in compliance with state and federal laws and regulations. Review of the job description titled, Director of Nursing read, The Director of Nursing Services assumes full administrative and clinical authority, responsibility and accountability for the delivery of nursing services in the facility. Manages employees in the provision of care and services according to professional standards of practice, consistent with facility philosophy of care and state and federal laws and regulations. Develops and implements policies and procedures consistent with current law. In collaboration with Nursing Home Administrator, allocates department resources in an efficient and economic manner to enable each resident to attain and maintain the highest practicable physical, mental, and psycho-social well-being. Collaborates with other departments, professionals, consultants, and organizations, including government agencies and advocacy groups, to develop support and coordination of resident care, related administrative functions and to represent the interests of the facility. Makes daily rounds on unit to supervise, observe, examine, interview residents, to evaluate staffing needs, to monitor regulatory compliance, to achieve the care environment and to evaluate staff interactions and clinical skills competency. Develops and maintains nursing policies and procedures that reflect current standards of nursing practice and facility philosophy of care consistent with state and federal laws and regulations. Communicates and interprets policies and procedures to nursing staff. Monitors practice for effective implementation. Hires and retains qualified competent nursing staff to provide nursing and nursing related services to attain or maintain highest practicable physical, mental, and psycho-social well-being of each resident. Conducts interviews, provides regular performance reviews, takes appropriate job actions, reviews job actions taken by subordinates to assure that staff meet qualification and performance standards and can perform all essential functions of the job. Review of the job description titled, Human Resources Manager read, Human Resources Manager is responsible for the overall administration, coordination and evaluation of the Human Resources function at the facility level. Implements all Human Resources Policies and Procedures. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Solves practical problems and deals with a variety of concrete variables in situations where only limited standardization exists. Acts as an employee advocate by performing the following duties: 1. Ensure that all policies, procedures, and reporting requirements are followed in compliance with corporate. 2. Recruits, interviews, tests, and assists department heads with selection of qualified employees to fill vacant positions. During an interview on [DATE] at 9:10 AM the Director of Nursing (DON) stated, I have recently taken over this job and did not hire that employee [Staff A]. I was here when the Administrator was notified that she was being investigated by [NAME] for identity theft of a nurse and they tracked her here by her cell phone. The administrator worked with that detective and the [name of the local law enforcement agency], and she was arrested here after she clocked in for her shift. Once we learned about this, we began an investigation. She had a background screening that came back eligible and did present a driver's license and social security card. Unfortunately, her license was in a different name. I can't tell you how this happened. We did not do the proper license verification. There were not any reference checks completed and her previous employers were not contacted to determine if she had actually worked for them. I don't know how this occurred. It should not have happened. We should never have hired her with the conflicting dates of birth and with the conflicting social security numbers. I do believe that it should have been escalated when she gave those, I think probably to the human resources' responsible person and the Administrator. After that we absolutely should have verified that she had a valid nursing license and requested that she bring in a copy of her license before we allowed her to work. During an interview on [DATE] at 4:18 PM Staff B, Licensed Practical Nurse (LPN) stated, I did run this persons [Staff A] AHCA (Agency for Healthcare Administration) background screen. I used to do all the background screenings and managed the roster and things like that. Once I completed those I would give them to HR [Human Resources] and then they would hire them in the system and do their part. Well, in April of 2022, Bedrock took over. They wanted my position to be more nursing and to do infection control, so then that's when the HR started taking over the backgrounds, but there was a transition, so I would still help [Staff C's name], like showing her how to resubmit backgrounds and how to pull new backgrounds so everything was complete. I did the background on [Staff A's name] in January after that I've given information to the HR, to [Staff C's name]. Well on our applications there is not a section for an employee's date of birth or social security number. I wrote the date of birth and social security number she gave me when I talked with her a few weeks after her interview when she let me know she wanted to proceed with becoming an employee. I then tried to do her background screening and she was not in the system with the original birthdate that she gave me. I wrote the [date written] and the social security number that is on there [the employee application]. So, then I had to call her and tell her I can't find her. That is when she told me that someone had stolen her identity and the government issued her new cards and a new birthdate. She then gave me a new birthdate and social security number. It was a different birthdate of [birth date given] and a new social security number. Once I put in the new information on the background screening, she came back as eligible, and it was the same person that I interviewed. I didn't think a thing, I have had others give me the wrong social security number so, I didn't think to escalate this to anyone else in HR. I did not tell [Staff C's name] about it. It did not concern me at all. I'm not a criminal so I believed her. Her background screening per AHCA came back eligible. I didn't question it all. I mean people mix up things, but when I put in her last name with that social her picture pulled up the social matched the date of birth on there and matched her picture that was on there, everything matched with the second date of birth . I did not bring any concerns about this to [Staff C's name], she cleared and was eligible. I did her interview. I do have the application in front of me when I interview. I didn't look at her education and ask her any questions about that. We just talked about her experiences, if she had taken [care of] trachs, her general experiences, if she was comfortable with g-tubes and medications. I didn't look at how her name was spelled and see that it was not the correct spelling. She did tell me that she got divorced and that's why there was a different name and that she had her identity stolen. I don't know how the license verification was done. The day that this was all being investigated we found out that the license verification wasn't in her file. I guess that's when she [Staff C] did it. I don't know when or if she did it when she [Staff A] was hired. I'm not HR. During an interview on [DATE] at 8:05 AM the Administrator stated, I have just assumed this role on Monday of this week. I am aware of the incident but have yet to fully review all the documentation. It was my understanding that the total investigation was handed over to the police when requested. In this case it appears that there was a failure in the HR process, it was not followed according to policy and procedure. I would expect that once two different IDs were given someone would have been notified. During a telephone interview on [DATE] at 9:20 AM the previous Nursing Home Administrator stated, I was notified on I believe it was 4/24 or [DATE] by a detective in [NAME] that they believed they had tracked a nurse with a fraudulent nursing license, and they were working in our building. I verified his identity and began to assist him in any way I could. Looking back at our files we determined that she [Staff A] gave two different social security numbers and she was called and changed her social security number and birth date. This got missed by [Staff B and Staff C's names]. I was not aware that the nursing license was not in the file and that she did not provide a copy of the nursing license. I would say the HR Manager should have caught this and brought it to the attention of someone when she gave multiple birthdays and social security numbers, that would be an immediate red flag. It should come to corporate HR and the Administrator. [Staff B's name] was well aware of the changing date of birth and social security number. At some point they both knew and should have responded, and we should not have hired her [Staff A]. We, upon investigation, suspended [Staff C's name] because she was in the role and had the responsibility to make sure that all aspects of the employment process is fully implemented and followed. Ultimately, administrators are responsible for the overall running of the building and all disciplines. This [Staff C's name] had been in HR since about last August or September, there is some debate on the amount of training she received, and she was learning on the fly. The mistake was made because they were not properly trained and did not understand the severity of the situation when [Staff B's name] was provided with two different birthdates and social security numbers. [Staff C's name] was in that role less than one year and they were trying to combine the role she had previously been in with HR responsibilities and make [Staff B's name] role more nursing. They put themselves [Bedrock] in this position by inadequately training [Staff C's name] to fulfill her role. During a telephone interview on [DATE] at 3:30 PM the Medical Director stated, I was notified immediately on Friday night that there was a nurse who was fraudulent and without a license that had been practicing with the residents. She was not properly cleared to work and the system to verify her license and identification was not followed. The police arrested her [Staff A] at the facility very late on Friday and we met on Monday to do a QAPI [Quality Assurance Performance Improvement] we did conduct the root cause. The names were different, and the nursing license was not verified. Luckily nothing happened to any of my residents nor other physicians' residents. It is imperative that we verify these things and have these systems in place, they promote and protect patients. They ensure that we provide a minimum standard of care that non licensed nurses cannot provide. There was great potential for harm if she had come across a situation that she was unfamiliar with. I hope we now have the system to safeguard all the residents in place and we will keep monitoring this to make sure this never happens again. She would not have the necessary knowledge to care for a tracheostomy tube, or possibly understand what to do if the resident accidentally decannulated [removed the tracheostomy] themselves. Gastrostomy tube medication administration is more complex with possible gastric perforation if not verified as present in the correct place and would require assessment skills that nurses have. Review of the policy and procedure titled, Employee Personnel Records dated [DATE] read, Policy: Bedrock care maintained certain records for each employee which are directly related to his/her employment. Policy interpretation and implementation: Federal and state regulations require that the facility maintain an individual personnel record for each employee. However, it shall be the employee's responsibility to provide the HR [Human Resources] Director with the required data. This responsibility also entails notifying, in writing, the HR Director of any change in the required data and keeping the required data current. Should it become necessary for an employee to furnish additional data or records, the employee will be notified in writing or electronically by the HR director, and such data must be completed and provided to the HR director within the time frame specified on the notice. Personnel records contain the following data: The employee's full name, address, date of birth , sex, and Social Security number, job application, job description(s), orientation and training program records, performance evaluations, employment references, letters, etc. Copy of current licenses (as applicable), others as appropriate or necessary, date of termination/discharge. The facility removed the immediacy and corrected the non-compliance as evidenced by: Review of the Root Cause Analysis provided by the facility was an untitled document provided by the facility, with no date or time indicated read, Problem statement: [Staff A's name] worked in nursing home without a valid license. Why? Detective notified facility of identity theft by [Staff A's name] questioning accuracy of nursing license. Why? Level 2 AHCA clearing house background [Staff A's name] eligible for employment. Why? Forms of identification matched spelling of name identical on Social Security and driver's license. Why? No results on OIG exclusion list [Staff A's name]. Why? License verification on FDOH (Florida Department of Health) [a different nurses name] clear/active root causes:1. Identity theft. 2. Spelling of name on driver's license and nurses license not match. 3. Middle name different on level 2 and nurse license. Review of the Performance Improvement Plan dated [DATE] documented [Medical Director's name] was notified of the removal of [Staff A's name] from the facility. The staff Developer and Regional Nurse conducted a quality review of 30 licensed nurses to ensure proper identification and valid and active nursing license in their file. Completed [DATE] for 30 of 30 licensed nurses. No discrepancies found. Seventy-seven resident assessments were completed by the Director of Nursing on residents that were provided care and services by [Staff A's name]. No areas of concern noted. Completed [DATE]. Discharge resident records were reviewed by the Director of nursing with no concern noted. Completed [DATE]. Medication Administration Records, Treatment Administration Records and narcotic sheets were reviewed by the Director of Nursing with no concern noted. Completed [DATE]. Grievances were reviewed by the Director of Nursing and no concerns with [Staff A's name] noted. Completed [DATE]. Education: The DON, Administrator, Human Resource Director and the Staff Developer were educated by the Staff Developer on Policy/Procedure: Employee Personnel Records to include the Employee's full name, address, date of birth , Social Security Number, job application, job description, orientation and training program records, performance evaluations and employment references; Policy/Procedure: New Hire Checklist; OIG Exclusion; AHCA Clearinghouse Roster; Verifying Active and Valid Nursing License; including the Original Nursing License and the Verified Active License placed in the Employee File. Completed [DATE]. Bedrock Rehabilitation and Nursing Center at Suwannee currently has 30 Licensed Nursing Staff. Current Licensed Nursing Staff received education by the Staff Developer and education was completed on [DATE]. Education included for Licensed Nursing Staff Policy/Procedure: Abuse/Neglect; Policy/Procedure: License Verification/proper acceptable identification. Completed [DATE]. One hundred sixty seven of 167 total employees received education by the staff developer on abuse and neglect. Completed [DATE]. Bedrock Rehabilitation and Nursing Center at Suwannee implemented a new hire checklist to ensure proper identification documentation is collected prior to employment. Completed [DATE]. On [DATE], harm no longer existed for the residents of Bedrock Rehabilitation and Nursing Center at Suwannee. Actions to prevent further deficient practice r/t licensed nurse identification discrepancy began on [DATE] are as follows: Newly hired Licensed Nurses will receive education in orientation, as stated above. The new hire checklist will be completed by the Human Resource Director with every newly hired Licensed Nurse to include verification of identification, employment history reference, and licensure verification. Review of the witness statements documented statements were completed by the Administrator of the facility at the time the incident occurred and by Staff B. An Ad Hoc [done for a particular purpose as necessary] Risk Management and QAA [Quality Assessment and Assurance] meeting was conducted on [DATE] with the development of a performance improvement plan as follows: The Ad Hoc meeting was attended by the Administrator, Director of Nursing, Medical Director, and Risk Manager with eight additional members in attendance. Policies included: Verifying nurse license and driver's license match exactly the names must match exactly. Identified clinical risks or safety hazards include: Employee practicing without a license. Employee distributed medications and rendered treatments without a nurse's license. Grievance log reviewed was documented as Yes. Complaints are a concern related to clinical issues, include employee practicing as a nurse without a license. Implementation of new employee checklist to be included in employee file: Employee information: Full name, job title. Pre employment: Application signed includes resume if applicable, test if applicable, background authorization/check clearing house Florida, OIG [Office of Inspector General] exclusion, WOTC [Work Opportunity Tax Credit], offer letter, references (2) 19 (if alien enter expiration date into Greymar [a healthcare operations software]), W4, EEOC [Equal Employment Opportunity Commission], disability, [NAME]. License/certification: license copy, license verification including out of state, CPR [cardiopulmonary resuscitation] copy, IV [intravenous] certification copy, scan and enter into Greymar. Review of an audit dated [DATE] documented the facility conducted interviews with all cognitively intact residents who were under the care of Staff A, there were no concerns identified. Seventy seven MAR/TAR reviews were completed. The Director of Nursing verified that all residents cared for by Staff A, 77 of 77 residents were assessed, 32 residents were interviewed. There were no concerns documented. Review of an audit dated [DATE] documented narcotic sheets and counts were reviewed for the east wing with no areas of concerns or discrepancies in narcotic counts. Review of an audit dated [DATE] documented the facility conducted 30 out of 30 Licensed staff photo identification and license verification. Review of an audit dated [DATE] documented the facility conducted 77 chart reviews on residents cared for by Employee to determine any changes in condition, transfer to hospital. There were no concerns identified. Review of an audit dated [DATE] documented on the New Hire Checklist implemented for all new hires. There were no nursing staff hired since [DATE]. Seven Certified Nursing Assistants (CNAs) were hired, with all required verifications and checklist present in employees' personnel files. Review of an audit dated [DATE] documented the Regional Nurse Consultant conducted education with the Administrator, DON, and Staff Educator, Staff Development Nurse, and HR Manager consisting of the New Hire process: Copy of license, license verification, 19. (two forms of approved identification with no issues identifying) OIG exclusion, Background Screening and adding to AHCA clearinghouse roster. Review of the in-service sign in sheets dated [DATE] documented Abuse and Neglect training and education was completed for 167 out of 167 employees. Review of the in-service sheet dated [DATE] documented the identity verification and nursing licensure requirement education completed by Staff Development Nurse for 30 out of 30 licensed staff. Interviews were conducted on [DATE] - [DATE] with 26 Certified Nursing Assistants, 12 Licensed Practical Nurses and 6 Registered Nurses who confirmed abuse and neglect training and education was provided. During interviews conducted on [DATE] the administrative staff verbalized understanding of the new hiring process and the actions to take if issues arise. Review of the 7 employee files for newly hired CNAs documented each employee file contained the New Hire Checklist, and identification and certifications matched. Review of the current licensed staff roaster for the period of [DATE] through [DATE] verified by employment dates there were no newly hired licensed nursing staff for this period of time.