**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect the residents' right to be free from neglect by failing to verify the identity, credentials, and licensure of individual prior to employment as a Licensed Practical Nurse, (LPN) providing care to 68 residents using a sample of 30 residents of a total of 117 residents in the facility, (#1 to #30). The unlicensed staff, Employee A to worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. Employee A was assigned to care for 68 residents including administering oral, optic (relating to eyes), inhalation, subcutaneous (beneath the skin), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube medications. Employee A provided insulin injections, blood glucose monitoring, performed wound care, respiratory care, monitored midline intravenous (IV) catheters, and completed nursing assessments. The facility failed to verify the education, training, and validation of nursing licensure for Employee A which allowed Employee A to perform the duties of a nurse without the assurance of safe, professional and ethical practice and accountability of a nursing license, which placed 68 residents under her care at likelihood of serious injury, harm or death due to possible medication and treatment errors and incorrect interpretation of laboratory tests. This resulted in Immediate Jeopardy starting on 02/07/2023. The Immediate Jeopardy was removed on 03/07/2023. The facility's noncompliance at F600 was corrected on 05/08/2023 and determined to be past noncompliance. Findings: Cross reference F607, and F835 Review of Employee A's Employment Application form revealed an application for employment at the facility was completed on 12/22/22. A professional license was verified by the facility via the Florida Department of Health License Verification website, using the license number provided by Employee A on her application. Data as of 12/22/2022 indicated the license was for a LPN, and was originally issued on 10/24/14, with expiration date of 7/31/23. The license status was documented to be clear and active. The Agency for Health Care Administration Care Provider Background Screening Clearinghouse (the state agency process for background screening results for health care providers in Florida currently licensed by the Agency for Health Care Administration) website page Person Profile showed employee A was determined to be eligible for employment on, 12/22/22, and on 1/26/23. The name on the Background Screening Clearinghouse reslts webpage was spelled differently from the name on the professional license, and the middle initial/names were different. A job description for LPN was signed by Employee A and dated 2/07/23. Employee A was employed at the facility from 2/07/23 to 3/07/23, and worked a total of sixteen shifts, beginning with orientation on 2/07/23 on the 3 PM to 11 PM shift. Review of the facility's staff schedules for the period 2/07/23 to 3/07/23, revealed employee A worked the following shifts, 3 PM to 11 PM, on 2/09/23, and 2/14/23, from 2:45 PM to 11:15 PM on 2/18/23, 3/04/23, and 3/06/23. Employee A did double shifts from 2:45 PM to 11:15 PM, and 10:45 PM to 7:15 AM on 2/19/23, 2/20/23, 2/25/23, 2/26/23, and on 3/05/23, and provided care and services for sixty-eight residents in teh capacity of a licensed nurse while not having a valid Florida nursing license. Review of clinical records revealed the following residents were provided with care and services from Employee A. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included sprain of anterior cruciate ligament of right knee, unilateral primary osteoarthritis, diabetes mellitus type II, psychosis, dementia, hyperlipidemia (high blood cholesterol), and peripheral vascular disease (a slow and progressive circulation disorder). Review of the Medication Administration Record (MAR) showed resident #1's administered medications on 2/09/23 at 5:00 PM included Loratadine 10 milligram (mg) by mouth for allergies, Fluticasone Propionate suspension 50 microgram (mcg)/Act 1 spray in each nostril for rhinitis, at 6:00 PM, Namenda 10 mg for dementia, Insulin Glargine injection 15 units for diabetes, at 9:00 PM, Latanoprost solution 1 drop in both eyes for glaucoma, Atorvastatin 40 mg by mouth for high cholesterol, and at 10:00 PM, Hydralazine 50 mg by mouth for high blood pressure, and Gabapentin 100 mg by mouth for neuropathy (damage to the peripheral nerves, and signs may include a prickling, burning or numb sensation). Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including, Alzheimer's disease, dementia, major depressive disorder, and malignant carcinoid tumor. Resident #2's administered medications on the MAR dated 2/25/23 at 6:00 PM included Divalproex 125 mg by mouth for seizures, at 6:30 PM, Aricept 5 mg by mouth for Alzheimer's, and at 9:00 PM, Trazadone 50 mg by mouth for depression. Resident #3 was admitted to the facility on [DATE]. His diagnoses included diabetes, major depressive disorder, anxiety disorder, Parkinson's disease, hypertension (HTN), and hyperlipidemia. The resident's MAR showed he received the following medications on 2/09/23, and 2/26/23 at 6:00 PM, Insulin Glargine injection 20 units, and at 9:00 PM Mirtazapine 30 mg by mouth for depression, and Topiramate 50 mg by mouth for mood disorder. Resident #4 was admitted to the facility on [DATE]. His diagnoses included high blood pressure, DM type II, atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and hyperlipidemia. The MAR noted resident #4's administered oral medications on 2/09/23 at 5:00 PM included, Memantine 10 mg, Metformin 1000 mg for diabetes, Gabapentin 500 mg, at 9:00 PM, Atorvastatin 20 mg, and Ropinirole 0.5 mg for Parkinson's. Employee A performed blood glucose monitoring for the resident at 4:30 PM, and 9:00 PM. Resident #5 was admitted to the facility on [DATE] with diagnoses that included heart failure, HTN, colostomy, chronic respiratory failure with hypoxia (a below normal level of oxygen in the blood), hyperlipidemia, quadriplegia, and chronic obstructive pulmonary disease (COPD). Resident #5's administered medications noted on the MAR dated 2/09/23 at 6:00 PM included Baclofen 20 mg by mouth for pain, at 9:00 PM Carvedilol 3.125 mg by mouth for heart failure, Acetylcysteine inhalation 20% for shortness of breath, and the resident's midline intravenous catheter (a samll tube used to give treatments and to take blood samples) was flushed with 10 milliliters (ml) of normal saline. Resident #6 was admitted to the facility on [DATE]. His diagnoses included cerebrovascular disease, aphasia (a disorder that results from damage to portions of the brain that are responsible for language), dysphagia (difficulty swallowing), HTN, and hyperlipidemia. The MAR showed the resident's administered medication on 2/09/23, and on 2/26/23 at 9:00 PM, included Atorvastatin 80 mg by mouth. Resident #7 was admitted to the facility on [DATE], with diagnoses which included HTN, dementia, COPD, and stroke. Resident #7's administered medications as per the MAR on 2/09/23, and on 2/26/23 at 6:00 PM included oral medications, Amlodipine 5 mg for high blood pressure, and Memantine 10 mg. Resident #8 was admitted to the facility on [DATE], with diagnoses that included depression HTN, seizures, DM type II, cerebrovascular disease, and hemiplegia (paralysis of one side of the body). The MAR showed the resident's administered medications on 2/09/23, and on 2/26/23 at 5:00 PM included oral medications, Levetiracetam 1000 mg for seizures, Metformin 500 mg, at 9:00 PM, Atorvastatin 80 mg, Baclofen 10 mg for muscle pain, Mirtazapine 30 mg, Gabapentin 600 mg, and at 10:00 PM Clindamycin 600 mg for infection. Blood glucose monitoring was documented as completed at 6:00 AM on 2/25/23 and 3/05/23. Resident #9 was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, HTN, dementia, anxiety disorder, major depressive disorder, and bone cancer. Resident #9's administered medications on 2/09/23, and 2/26/23 at 5:00 PM included Docusate 100 mg by mouth for constipation, at 6:30 PM, Tamsulosin 0.4 mg by mouth for enlarged prostate, at 9:00 PM, Latanoprost 0.005% 1 drop in both eyes, and at 10:00 PM Brimonidine Tart 0.2% 1 drop in both eyes for glaucoma. Resident #10, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms such as depression or mania), delusional disorders, anxiety disorder, major depressive disorder, HTN, COPD, dementia, and traumatic brain injury. Resident #10's administered medications on 2/09/23, and 2/26/23 at 5:00 PM included Valproate Sodium 15 ml by mouth for mood disorder, 9:00 PM Latanoprost 0.005% 1 drop in both eyes, Mirtazapine 7.5 mg by mouth, Quetiapine 400 mg by mouth for schizoaffective disorder, and at 10:00 PM Baclofen 10 mg by mouth for muscle spasm. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute osteomyelitis (infection of bone), DM type II, hemiplegia/hemiparesis affecting left non-dominant side, long term use of anticoagulants (blood thinners), HTN, atrial fibrillation, and hyperlipidemia. Resident #11's administered medications on the MAR on 2/09/23, and 2/26/23 at 9:00 PM included oral medications, Atorvastatin 10 mg, Apixaban 5 mg for blood clot prevention, and Glimepiride 4 mg for diabetes. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included aphasia, frontal lobe and executive function deficit, metabolic encephalopathy (metabolism problems that cause brain dysfunction), DM type II, HTN, and peripheral vascular disease. Resident #12's administered medications on the MAR dated 2/09/23, and 2/26/23 at 5:00 PM included Carvedilol 12.5 mg by mouth, at 9:00 PM Insulin Glargine 10 units injection, Lisinopril 20 mg by mouth for high blood pressure, Gabapentin 100 mg, and Hydralazine 100 mg, both by mouth. Resident #13, an [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included DM type II, major depressive disorder, Alzheimer's disease, and dementia. Resident #13's administered medications on 2/09/23, and 2/26/23 at 9 PM included oral medications, Atorvastatin 20 mg, and Norvasc 5 mg for high blood pressure. Resident #14 was admitted to the facility on [DATE], with diagnoses which included HTN, aphasia, depression, hemiplegia, and hyperlipidemia. Resident #14's administered oral medications on 2/09/23, and 2/26/23 at 5 PM included, Loratadine 10 mg for rhinitis, and at 9 PM, Lipitor 20 mg for high cholesterol, Mirtazapine 15 mg, Levetiracetam 1000 mg, Lisinopril 20 mg, and Gabapentin 300 mg. Resident #15, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included hyperlipidemia, hypothyroidism (low thyroid hormones), dementia, psychosis, convulsions, bipolar disorder, major depressive disorder, and schizoaffective disorder. Resident #15's oral administered medications on 2/18/23, and 2/19/23 at 4:30 PM included Keppra 1000 mg for seizures, at 5 PM Depakote 500 mg, and at 6 PM Potassium Chloride 20 milliequivalents (MEQ). On 2/19/23, 2/20/23, and 2/26/23, at 6 AM employee A administered Levothyroxine 150 microgram (mcg) for hypothyroidism, at 6:30 AM Keppra 1000 mg, at 6 PM Lasix 40 mg, Lasix 20 mg for edema, at 6:30 PM Aptiom 400 mg for convulsions, at 9 PM, Seroquel 150 mg for schizoaffective disorder, Simvastatin 20 mg. On 3/04/23, 3/05/23, and 3/06/23 at 4:30 PM Keppra 1000 mg, 6 PM Lasix 20 mg, Lasix 40 mg, Potassium Chloride 20 milliequivalents (MEQ), at 6:30 PM Aptiom 400 mg, and at 9 PM Seroquel 150 mg, Simvastatin 20 mg for high cholesterol, Carvedilol 12.5 mg, and Depakote 500 mg for bipolar disorder. Resident #16, a 59- year-old female was admitted on [DATE]. Her diagnoses included hemiplegia/hemiparesis, anxiety disorder, insomnia, major depressive disorder, hypercholesterolemia, and epilepsy. Resident #16's oral administered medications on 2/09/23, and 2/26/23 at 5 PM included Keppra 1000 mg, Ciprofloxacin 500 mg for abscess, and at 9 PM Pravastatin 20 mg for cholesterol, Clonazepam 2 mg for anxiety, and Temazepam 7.5 mg for insomnia. Resident #17, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses which included aphasia, atrial fibrillation, Alzheimer's disease, hyperlipidemia, insomnia, HTN, and Parkinson's disease. Resident #17's oral administered medications on 2/09/23, and 2/26/23 at 6 PM included Coumadin 5 mg for blood clot prevention, and at 9 PM Atorvastatin 10 mg. Resident #18, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia, DM type II, tachycardia (fast heart rate over 100 beats/minute), HTN, cerebral infarction, and hyperglycemia (high blood sugar). Resident #18's administered medications on 2/09/23, and 2/26/23 at 5 PM included, Humalog insulin injection 3 units, at 9 PM Atorvastatin 40 mg by mouth, Insulin Glargine 15 units injection, Metoprolol 25 mg by mouth for high blood pressure, Baclofen 10 mg by mouth, and Gabapentin 300 mg by mouth. Resident #19, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included DM type II, HTN, hyperlipidemia, and gastroesophageal reflux disease (GERD). Resident #19's administered medications on 2/09/23, and 2/26/23 at 5 PM included Humalog insulin injection 20 units, at 6 PM Losartan Potassium 50 mg for high blood pressure by mouth, Metformin 500 mg by mouth, and at 9 PM, Atorvastatin 40 mg by mouth, Lantus insulin injection 73 units, and Hydralazine 100 mg by mouth. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE], with diagnoses which included heart failure, hyperlipidemia, hypokalemia, atrial fibrillation, DM type II, and HTN. Resident #20's administered oral medications on 2/09/23, and 2/26/23 at 9 PM included, Apixaban 5 mg, and Metoprolol 50 mg. Resident #21, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included major depressive disorder, chronic kidney disease, hyperlipidemia, HTN, gastrostomy, and dementia. Resident #21's administered medications by gastrostomy tube on 2/09/23 at 6 PM included Carvedilol 3.125 mg, at 4 PM and 8 PM Employee A's signature on the Medication Administration Record indicated the resident's gastrostomy tube was flushed with 150 ml of water. Documentation indicated the gastrostomy tube was checked for placement (in the digestive tract), patency (tube being blocked) residual (volume of feeding remaining in the stomach), the site was observed for signs and symptoms of infection and the tube was flushed with 30 ml of water before and after medication administration through the tube. Resident #22, a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included COPD, hemiplegia/hemiparesis, anxiety disorder, HTN, major depressive disorder, and hyperlipidemia. Resident #22's administered oral medications on 2/09/23 at 9 PM included Atorvastatin 40 mg, Levothyroxine 150 mg, Melatonin 6 mg for insomnia, and Ciprofloxacin 500 mg for infection. Resident #23, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included bipolar disorder, anxiety disorder, and pneumonia. Resident #23's oral administered medications on 2/14/23, and 2/25/23 at 9 PM included, Seroquel 100 mg, Trazadone 50 mg, Alprazolam mg for anxiety, and at 10 PM Gabapentin 300 mg. Resident #24, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included DM type II, Alzheimer's disease, HTN, and COPD. Resident #24's administered oral medications on 2/25/23, and on 2/26/23 at 6 AM included, Eliquis 2.5 mg for clot prevention, at 6 PM Eliquis 2.5 mg (for blood clot prevention), and at 9 PM Atorvastatin 20 mg. Resident #25, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction, major depressive disorder, atrial fibrillation, heart failure, paranoid schizophrenia, hyperlipidemia, hemiplegia/hemiparesis, DM type II, and HTN, PVD. Resident #25's administered medications on 2/09/23, and 2/26/23 at 6 PM included digoxin 125 mcg by mouth for atrial fibrillation, Apixaban 5 mg by mouth, Baclofen 5 mg by mouth, Carvedilol 25 mg by mouth, Valproate Sodium 200 mg by mouth, at 9 PM Lantus insulin injection 50 units, Diltiazem 90 mg by mouth for high blood pressure, and at 10 PM Keppra 500 mg by mouth, and Hydralazine 100 mg by mouth. Resident #26, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, anxiety disorder, HTN, and hyperlipidemia. Resident #26's administered medications on 2/09/23, and on 2/26/23 at 10 PM included, Atorvastatin 40 mg by mouth. Resident #27, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end stage renal disease (ESRD), major depressive disorder, insomnia, hypokalemia, and convulsion. Resident #27's oral administered medications on 2/09/23, and 2/26/23 at 9 PM included, Trazadone 50 mg, Pregabalin 50 mg for neuropathy, Melatonin 3 mg, and Valproic Acid 15 ml for tremors. Resident #28, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy, dementia, HTN, and dysphagia. Resident #28's administered medications on 2/14/23 at 2 PM included Medrol 4 mg by mouth for cellulitis, at 6:30 PM Medrol 4 mg by mouth, at 9 PM, Clonazepam 0.5 mg by mouth for anxiety, Atorvastatin 20 mg by mouth, Medrol 4 mg by mouth, Risperidone 0.25 mg by mouth for mood, and Trazadone 50 mg by mouth. At 2:58 PM documentation on the resident's Medication Administration Record indicated Employee A interpreted tuberculosis skin test for the resident and administered the Pneumovax vaccine (vaccine helps protect against pneumonia) by injection at 3:02 PM. Resident #29, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included DM type II, cancer of the pancreas, dementia, hypothyroidism, hyperlipidemia, and HTN. Resident #29's administered medications on 2/14/23 at 9 AM included Amlodipine 2.5 mg by mouth, Latanoprost solution 0.005% 1 drop in both eyes, Toprol 50 mg by mouth for high blood pressure, at 5 PM Rivaroxaban 20 mg by mouth for atrial fibrillation, and at 9 PM Simvastatin 20 mg by mouth. Resident #30, a [AGE] year-old female was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included major depressive disorder, hyperlipidemia, DM type II, HTN, heart disease, ventricular tachycardia, and dementia. Resident #30's administered medications via gastrostomy tube on 2/14/23, and 2/25/23 at 10 AM included, Amlodipine 5 mg, Furosemide 20 mg for heart disease, at 9 PM Atorvastatin 20 mg, Metoprolol 25 mg, and on 2/25/23 at 5 PM Doxycycline 100 mg for wound infection. Brimonidine-Timolol ophthalmic solution 0.5% 1 drop in both eyes for glaucoma was adminstered at 9 PM. Employee A's signature on the resident's Medication Administration Record indicated the resident's gastrostomy tube was flushed with 150 ml of water, and the tube feed formula Osmolite 1.5 was administered at 45 ml per hour. Documentation indicated the gastrostomy tube was checked for placement, patency, residual, observed for signs and symptoms of infection and the tube was flushed with 30 ml of water before and after medication administration through the tube. On 5/10/23 at 10:26 AM, the Director of Nursing (DON) stated that on 5/03/23 at approximately 2:30 PM the Human Resource (HR) Director was notified via telephone by a Law Enforcement Officer, from the criminal investigation division, that they had initiated an investigation related to identity theft, and were questioning the accuracy of nursing license for Employee A. On 5/10/23 at 10:49 AM, and on 5/25/23 at 9:56 AM, the Business Office Manager/ Human Resources (HR) Director stated the process for new hires, included a completed application, and an interview with the DON. She explained that if the applicant was approved, HR would do a license verification through the Florida Department of Health (the Florida state agency responsible for regualtion of licensed health care practitioners) and the Agency For Healthcare Administration (AHCA) Level II background screening and would conduct a search via the Office of the Inspector General (OIG) to see if the prospective employee was eligible to work. The Business Office Manager/ HR Director stated Employee A applied to the facility on 12/ 22/22 via, Indeed .com (an American worldwide employment website for job listings) and an interview was conducted by the DON on 12/22/22. References were obtained for Employee A from a skilled nursing facility, and from a past coworker whom she worked with on a Rapid Response team, and the professional license was verified, and pulled from the Department of Health website. The Business Office Manager/HR Director recalled she contacted both references, and received positive feedback regarding Employee A. The Business Office Manager/HR Director stated Employee A needed fingerprints done, so she was sent out to a company contracted by the facility to have her fingerprints done. She stated Employee A's information was submitted to the company on 12/22/22, and she was determined to be eligible to work on 12/28/22. The Business Office Manager/ HR Director recalled that Employee A stated she could not start at that time since she had another job, and her background was run again on 1/17/23. She explained that it was the practice of the facility to resubmit the request for background screen, so that if something comes up, AHCA (Background Screening Clearinghouse) would catch it. The Business Office Manager/HR Director stated Employee A was eligible to work on 1/26/23, and her first day of work at the facility was on 2/07/23. The Business Office Manager/HR Director stated that when she ran the professional license, using the license number provided by Employee A nothing flagged indicating the license was clear and active. She recalled she also checked employee A's Social Security (SS) card and driver's license. The Business Office Manager/ HR Director recalled the name on the professional license and Employee A's driver's license were different, the first names were spelt differently, and there were different middle names. She stated she did not compare the names on the professional license and the driver's license and did not ask Employee A about the different spelling of the names. The Business Office Manager/HR Director stated she did not notice the discrepancy at that time. She stated she did not line up all the documents and review them thoroughly for accuracy On 5/25/23 at 11:02 AM, the DON recalled she interviewed Employee A on 12/22/22, and verbalized the employee had good customer service, was very knowledgeable, and showed knowledge regarding the fundamentals of nursing. The DON stated she reviewed Employee A's application, discussed her schooling, but never reviewed her license/certificate or asked for a transcript. She stated her level II background screen had to be cleared before she could start working, and she started orientation on 2/07/23 with mostly observation. On 2/09/23 she had an assignment with oversight from a preceptor, and on 2/14/23, Employee A was on a medication cart by herself. The DON verbalized that no one picked up the discrepancy with the names on Employee A's driver's license, SS card, and the LPN license. She confirmed employee A administered medications via gastrostomy tube, maintained gastrostomy tube feeding, administered insulin injections and other oral and optic medications. On 5/25/23 at 11:24 AM, the Administrator stated Employee A was already hired at the facility when she started, and she recalled she was made aware of the issues with the Employee's license when the detective notified the facility on 5/03/23. The Administrator said Employee A was already terminated due to absenteeism, and being late frequently. She stated the facility did not verify the spelling of the names on the documents provided by Employee A. On 5/25/23 at 11:28 AM, the Medical Director explained he was made aware of the employee working at the facility as a LPN without a license when he attended a meeting with the Administrator, Regional Consultant Nurse, and the DON on 05/03/2023. He stated he was shocked, and was concerned if any resident was harmed. He said he was pleased the facility had assessed the residents by doing clinical reviews of records and interviews and also reviewing all transfers to the hospital that identified there was no harm done to the residents. The Medical Director stated he attended the Ad Hoc Quality Assurance Performance Improvement (QAPI) and agreed with steps taken to address the issue. He stated nurses usually paged him on his paging service, but he had no recollection of having any interaction with Employee A. 5/26/23 at 3:50 PM, the Administrator, and the Regional Nurse Consultant stated the facility did not have a policy regarding the hiring process, but followed the State guidelines, and the facility's policy and procedure for Abuse, Neglect, Exploitation (ANE). Review of the facility's policy and procedure ANE and Investigations issued 4/01/2022, revealed the screening process for potential employees included a Level II FBI (Federal Bureau of Investigation) finger printing if they have not had one conducted in the previous 5 years. The document read, All health care providers that require licensure or certification will be verified prior to provision of care of residents. The job description for Human Resources Manager with revision date of 1/01/2015 read, The primary purpose of your position is to provide Human Resources in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as directed by the Administrator, to assure that quality personnel are interviewed, trained and employed Ensure hiring .procedures comply with established policies and procedures .Hire personnel in accordance with established hiring practices. Review of the job description for Director of Nursing Services with revision date of 1/1/2015 revealed, the job duties and responsibilities included recommendation of the number and level of nursing personnel to be employed .Develop, maintain, and periodically update the written procedure for ensuring that professional nursing personnel, including private duty nurses, have valid and current licenses as required by this State Ensure that direct nursing care be provided by LPNs . qualified to perform the procedure .Assist the Administrator and/or the HR Director in the recruitment and selection of nursing service personnel . Ensure that direct nursing care be provided by LPNs .qualified to perform the procedure. The job description for Licensed Practical Nurse/Registered Nurse with revision date of 1/01/2015 read, The primary purpose of your position is to provide direct nursing care to the residents, . Ensure that direct nursing care be provided by a licensed nurse .Administer professional services such as: catheterization, tube feedings, suction, applying and changing dressings and bandages, packs, colostomy, and drainage bags . as required . Take and record TPRs, blood pressures, .Monitor seriously ill residents as necessary . Must possess, at a minimum, a Nursing Degree from an accredited college or university, or graduate from an approved LPN/LVN/RN program. Must possess a current, unencumbered, active license to practice as an .LPN/LVN (Licensed Vocational Nurse) in this state. Review of the Facility Assessment 2023 updated 4/12/23, reviewed on 4/17/23 indicated that resources needed to provide competent support and care for our resident population every day and during emergencies, included Nursing services-LPN Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: Employee A was terminated on 3/07/23, and her last working day at the facility was 3/06/23. *On 5/03/23 the HR Director was notified via telephone by a detective from the criminal investigation division, that an investigation related to identity theft, and the accuracy of nursing license was initiated pertaining to Employee A. *On 5/03/23 the facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting, and revealed the root cause(s) were, Identity theft, and that Employee A's driver's license, and level II background screen was not validated for accuracy of demographics. A Performance Improvement Plan (PIP) was initiated, objective and goal was, Services are provided by qualified personnel: Focused area: Licensed Nurse. *On 5/03/23 the facility initiated an investigation regarding validity Employee A's license. *Initiated investigation to ensure care and services were provided to residents the employee was assigned to. * Employee Record review conducted revealed Employee A worked from 2/07/23 to 3/06/23. Terminated on 3/07/23 for absence attendance, and tardiness. Verified absence of nursing license, Law enforcement notified, and Florida Department Of Health (FL DOH) reporting filed via practitioner complaint process. * Cross check for applicable employees holding a licensure/certification done to ensure: Licensed nurse/CNA/Therapist/ verification report retrieved from FL DOH website Nurses' professional license validated with driver's license and Level II background screen (BGS), verified by two employees (HR and Administrator/designee). *Current employees verified via employee roster, BGS clearinghouse website. *Residents currently in facility assessed by licensed nurse-(oversight by RN) any issues/concerns communicated to attending physician/family/responsible party *Resident interviews conducted with residents with Brief Interview for Mental Status (BIMS) score of 12 out of 15 or greater, skin checks conducted for those with BIMS 11 out of 15 and below to ensure facility was free from Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown source (ANEMMI). No concerns were noted. A BIMS score of 0 to 7 indicates severely impaired cognition, a score of 8 to 12 indicates moderately impaired cognition, a score of 13 to 15 indicates intact cognition. *Medication carts were reviewed to ensure narcotic counts correct; no concerns noted. *Comprehensive review of care and services carried out to include Risk management and AHCA federal reportable events from 2/07/23 to 3/07/23 reviewed to ensure there were no deviations from practice regarding: nursing care, reviewed falls, grievance log, concerns, hotline complaints, return to hospital, to ensure no deviation of practice. Resident representatives of residents' Employee A cared for were notified of unlicensed activity. *Licensed Nursing hours reviewed for days Employee A worked, hours for days identified removed. *Initiated educ

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement policies and procedures to prevent medical neglect by failing to verify identification, and licensure of Employee A prior to employment as a Licensed Practical Nurse (LPN)providing care and services to 68 residents during 16 shifts using a sample of 30 residents of a total of 117 residents in the facility, (#1 to #30). The unlicensed staff, Employee A worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. Employee A was assigned to care for 68 residents including administering oral, optic (related to eyes), inhalation, subcutaneous (beneath the skin), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube medications. Employee A provided insulin injections, blood glucose monitoring, performed wound care, respiratory care, monitored midline intravenous (IV) catheters, and completed nursing assessments. The facility failed to implement policies and procedures for verification of identification, and licensure for nursing staff prior to performing nursing duties which allowed Employee A to perform the duties of a nurse without the assurance of safe, professional and ethical practice and accountability of a nursing license, and placed 68 residents under her care at a likelihood of serious, injury, harm or death due to possible medication and treatment errors and incorrect interpretation of laboratory tests. This resulted in Immediate Jeopardy starting on 2/07/23. The Immediate Jeopardy was removed on 03/07/2023. The facility's noncompliance at F607 was corrected on 05/08/2023 and determined to be past noncompliance. Findings Cross reference F600 and F835 Review of Employee A's Employment Application form revealed an application for employment at the facility was completed on 12/22/22. A professional license was verified by the facility via the Florida Department of Health License Verification website, using the license number provided by Employee A on her application. Data as of 12/22/2022 indicated the license was for an LPN, and was originally issued on 10/24/14, with an expiration date of 7/31/23. The license status was documented to be clear and active. The Agency for Health Care Administration Care Provider Background Screening Clearing House (the state agency process for background screening results for health care providers in Florida currently licensed by the Agency for Health Care Administration) website page) Person Profile showed Employee A was determined to be eligible for employment on, 12/22/22, and on 1/26/23. The name on the Background Screening Clearinghouse results webpage was spelled differently from the name on the professional license, and the middle initial/names were different. Employee A was employed at the facility from 2/07/23 to 3/07/23, and worked a total of sixteen shifts, beginning with orientation on 2/07/23 on the 3 PM to 11 PM shift. Review of the facility's staff schedules for the period 2/07/23 to 3/07/23, revealed Employee A worked the following shifts, 3 PM to 11 PM, on 2/09/23, and 2/14/23, from 2:45 PM to 11:15 PM on 2/18/23, 3/04/23, and 3/06/23. Employee A did double shifts from 2:45 PM to 11:15 PM, and 10:45 PM to 7:15 AM on 2/19/23, 2/20/23, 2/25/23, 2/26/23, and on 3/05/23, and provided care and services for sixty-eight residents in the capacity of a licensed nurse while not having a valid Florida nursing license. Review of thirty sampled residents' clinical records revealed they were provided with care and service from Employee A including administering oral, optic, inhalation, subcutaneous, and gastrostomy tube medications. Employee A provided insulin injections, blood glucose monitoring, monitored midline IV catheter, interpreted tuberculin test, provided pneumococcal vaccine, wound care, respiratory care and completed nursing assessments, with the likelihood of serious harm or death due to lack of credentials and competency. On 5/10/23 at 10:26 AM, the Director of Nursing (DON) stated that on 5/03/23 at approximately 2:30 PM, the Human Resource (HR) Director was notified via telephone by Law Enforcement Officer, from the criminal investigation division, that they had initiated an investigation related to identity theft, and were questioning the accuracy of nursing license for Employee A. On 5/10/23 at 10:49 AM, and on 5/25/23 at 9:56 AM, the Business Office Manager/ Human Resources (HR) Director stated the process for new hires, included a completed application, and an interview with the DON. She stated that if the applicant was approved, HR would do a license verification through the Florida Department of Health, (the Florida state agency responsible for regulation of licensed health care practitioners) and the Agency for Healthcare Administration (AHCA) Level II background screening and would conduct a search via the Office of the Inspector General (OIG) to ensure the prospective employee was eligible to work. The Business Office Manager/HR Director stated Employee A completed her application to the facility on [DATE]. She noted the results of her fingerprint and background screening were received on 12/28/22, and Employee A started orientation at the facility on 2/07/23. The Business Office Manager/HR Director explained that when she verified the professional license, using the license number provided by Employee A, nothing flagged, which indicated the license was clear and active. She recalled she also checked Employee A's Social Security (SS) card and recalled the name on the professional license and Employee A's driver's license were different. The first names were spelled differently, and there were different middle names. She stated she did not compare the names on the professional license and the driver's license and did not ask Employee A about the different spelling of the names. The Business Office Manager/HR Director stated she did not notice the discrepancy at that time, and did not review all the required documents thoroughly prior to the hiring of Employee A. On 5/25/23 at 11:02 AM, the DON recalled she interviewed Employee A on 12/22/22. She stated Employee A had good customer service, was very knowledgeable, and showed knowledge regarding the fundamentals of nursing. The DON stated she reviewed Employee A's application, discussed her schooling, but never reviewed her license/ certificate or asked for a transcript. She stated no one picked up on the discrepancy with the names on Employee A's driver's license, SS card, and the LPN's license. She acknowledged Employee A administered medications via gastrostomy tube, maintained gastrostomy tube feedings, and administered insulin injections and other oral and optic medications during the period she worked at the facility. On 5/25/23 at 11:24 AM, the Administrator stated Employee A was already hired at the facility when she started, and she recalled she was made aware of the issues with the employee's license when the detective notified the facility on 5/03/23. The Administrator said Employee A was already terminated due to absenteeism, and being late frequently. She stated the facility did not verify the spelling of the names on the documents provided by Employee A prior to her hire. On 5/26/23 at 3:50 PM, the Administrator, and the Regional Nurse Consultant stated the facility did not have a policy regarding the hiring process, but followed the State guidelines, and the facility's policy and procedure for Abuse, Neglect, Exploitation (ANE). Review of the facility's policy and procedure ANE and Investigations issued 4/01/2022, revealed the screening process for potential employees included a Level II Federal Bureau of Investigation (FBI) finger prints if one was not done in the previous 5 years. The document read, All health care providers that require licensure or certification will be verified prior to provision of care of residents. The job description for Human Resources Manager with revision date of 1/01/2015 read, The primary purpose of your position is to provide Human Resources in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as directed by the Administrator, to assure that quality personnel are interviewed, trained and employed Ensure hiring .procedures comply with established policies and procedures .Hire personnel in accordance with established hiring practices. Review of the job description for Director of Nursing Services with revision date of 1/1/2015 revealed, part of the job duties and responsibilities was to Develop, maintain, and periodically update the written procedure for ensuring that professional nursing personnel, including private duty nurses, have valid and current licenses as required by this State Ensure that direct nursing care be provided by LPNs .qualified to perform the procedure. Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: Employee A was terminated on 3/07/23, and her last working day at the facility was 3/06/23. *On 5/03/23 the HR Director was notified via telephone by a detective from the criminal investigation division, that an investigation related to identity theft, and the accuracy of nursing license was initiated pertaining to Employee A. *On 5/03/23 the facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting, and revealed the root cause(s) were, Identity theft, and that Employee A's driver's license, and level II background screen was not validated for accuracy of demographics. A Performance Improvement Plan (PIP) was initiated, objective and goal was, Services are provided by qualified personnel: Focused area: Licensed Nurse. *On 5/03/23 the facility initiated an investigation regarding validity Employee A's license. *Initiated investigation to ensure care and services were provided to residents the employee was assigned to. * Employee Record review conducted revealed Employee A worked from 2/07/23 to 3/06/23. Terminated on 3/07/23 for absence attendance, and tardiness. Verified absence of nursing license, Law enforcement notified, and Florida Department Of Health (FL DOH) reporting filed via practitioner complaint process. * Cross check for applicable employees holding a licensure/certification done to ensure: Licensed nurse/CNA/Therapist/ verification report retrieved from FL DOH website Nurses' professional license validated with driver's license and Level II background screen (BGS), verified by two employees (HR and Administrator/designee). *Current employees verified via employee roster, BGS clearinghouse website. *Residents currently in facility assessed by licensed nurse-(oversight by RN) any issues/concerns communicated to attending physician/family/responsible party *Resident interviews conducted with residents with Brief Interview for Mental Status (BIMS) score of 12 out of 15 or greater, skin checks conducted for those with BIMS 11 out of 15 and below to ensure facility was free from Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown source (ANEMMI). No concerns were noted. A BIMS score of 0 to 7 indicates severely impaired cognition, a score of 8 to 12 indicates moderately impaired cognition, a score of 13 to 15 indicates intact cognition. *Medication carts were reviewed to ensure narcotic counts correct; no concerns noted. *Comprehensive review of care and services carried out to include Risk management and AHCA federal reportable events from 2/07/23 to 3/07/23 reviewed to ensure there were no deviations from practice regarding: nursing care, reviewed falls, grievance log, concerns, hotline complaints, return to hospital, to ensure no deviation of practice. Resident representatives of residents' Employee A cared for were notified of unlicensed activity. *Licensed Nursing hours reviewed for days Employee A worked, hours for days identified removed. *Initiated education- Abuse, Neglect, Exploitation 138/139 staff educated, 100% completed on 5/05/23. *On 5/03/23 Abuse, Neglect, Exploitation (ANE) completed for residents in Employee A's assignment on 2/09/23, 2/14/23, 2/18/23, 2/19/23, 2/20/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 3/04/23, 3/05/23, and 3/06/23 indicated no concerns, interviewed families of residents with BIMS below 10. *Conducted full house audit for ANE: to ensure no care concerns. Questions included: Do you have any safety concerns? Do you have any care concerns? Do you have any concerns or feel that you may have been neglected, abused, mistreated, exploited and/or misappropriation. *On 5/03/23 4 of 4 persons responsible for obtaining initial verification and ongoing monitoring of licensure and certification status re-educated on facility process for: validating License/Certification status/obtaining BGS and license verification with validation of demographics by two staff members for accuracy. Licensed nurse verification of demographic accuracy to be validated with (HR and administrator) for all active licensed nurses. *Licensed Nurse verification report validation with driver's license and level II BGS for validation of demographic accuracy to be validated with (HR and Administrator) for all active licensed nurses. *Systemic Changes: The facility initiated a cross-check process to include Onboarding- facility will determine and validate proper education, certification, licensing for positions applying for- by HR and director of hiring department. Obtain copy of driver's license/government issued ID, verify license through FL DOH Medical Quality Assurance (MQA) site and validate demographics accuracy on level II AHCA background clearing house, to be reviewed/validated by HR and Administrator and/or DON. *Beginning 5/03/23 the facility Administrator/designee reviewed concern/grievance log, 24/72 -hour report, resident/family council meetings, facility compliance /complaint line, risk management portal, electronic health record, alert reporting during the stand up/stand down administrative/clinical morning meetings. *On 5/04/23 an Immediate ACHA report was submitted. * SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note for RNs/LPN/LVNs for all residents in Employee A's assignment evaluated by Licensed nurse, medical records reviewed with the Medical Director, plan of care reviewed- no changes in condition noted. Responsible parties made aware of unlicensed staff activity. * On 5/08/23 an additional Ad Hoc QAPI was held to review actions implemented. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown origin, and the importance of licensure/certification rules and regulations for applicable employees such as nursing/CNA/Therapist. Review of the audit titled, Licensed Nurse/Agency/Student/volunteer Log revealed the log would be utilized by the Human Resources Director/designee and Director of Nursing/designee to review photo identification, licensure/certification (if applicable) and Level II Background Screening/State specific background screening. The log indicated audits were conducted on 5/05/23 and 5/08/23, and all components were identified, and in compliance with required regulations and facility's policy and procedures. On 5/10/23, and 5/26/23, interviews were conducted with three Registered Nurses, five LPNs, three CNAs, three Rehab staff, one Receptionist, and one housekeeping staff, All verbalized understanding of the education provided. On 5/26/23, interviews were conducted with four of four people responsible for obtaining initial verification and ongoing monitoring of licensure and certification status. They verbalized understanding of the education provided. The surveyor determined based on the facility's corrective actions, the facility was in substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility's administration failed to use its resources effectively to ensure policies and procedures were implemented to prevent medical neglect placing 68 residents in the facility at risk by not verifying identification and licensure of an individual prior to employment as a Licensed Practical Nurse (Employee A) assigned to provide nursing care and services for 68 residents on 16 shifts while working in the capacity of a LPN without a valid license. The unlicensed staff, Employee A worked in the capacity of a Licensed Practical Nurse (LPN) starting on 02/07/2023 at the facility. The facility failed to validate information and documents presented, and Employee A who was not a licensed nurse, worked as a LPN for 16 shifts at the facility from 2/07/23 to 3/07/23. Employee A was assigned to care for 68 residents including administering oral, optic (relating to eyes), inhalation, subcutaneous (beneath the skin), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube medications. Employee A provided insulin injections, blood glucose monitoring, performed wound care, respiratory care, monitored midline intravenous (IV) catheters, and completed nursing assessments. The facility failed to verify the education, training, and validation of nursing licensure for Employee A, which allowed Employee A to perform the duties of a nurse, without the assurance of safe, professional and ethical practice and accountability of a nursing license, which placed the 68 residents under her care at a likelihood of serious injury, harm, or death. The facility administration's failure to use its resources effectively to ensure policies and procedures were implemented to prevent medical neglect resulted in Immediate Jeopardy starting on 2/07/23. The Immediate Jeopardy was removed on 03/07/2023. The facility's noncompliance at F835 was corrected on 05/08/2023 and determined to be past noncompliance. Findings Cross reference F600, F607 Employee A was employed at the facility from 2/07/23 to 3/07/23, and worked a total of sixteen shifts, beginning with orientation on 2/07/23 on the 3 PM to 11 PM shift. Review of the facility staff schedule for the period 2/07/23 to 3/07/23, revealed Employee A worked the following shifts, 3 PM to 11 PM, on 2/09/23, and 2/14/23, from 2:45 PM to 11:15 PM on 2/18/23, 3/04/23, and 3/06/23. Employee A did double shifts from 2:45 PM to 11:15 PM, and 10:45 PM to 7:15 AM on 2/19/23, 2/20/23, 2/25/23, 2/26/23, and on 3/05/23, and provided care and services for sixty-eight residents in the capacity of a licensed nurse while not having a valid Florida nursing license. On 5/10/23 at 10:49 AM, and on 5/25/23 at 9:56 AM, the Business Office Manager/ Human Resources (HR) Director stated the process for new hires, included a completed application, and an interview with the Director of Nursing (DON). She stated that if the applicant was approved, HR would do a license verification through the Florida Department of Health (the Florida state agency responsible for regulation of licensed health care practitioners), and the Agency For Healthcare Administration (AHCA) Level II background screening and would conduct a search via the Office of the Inspector General (OIG) to ensure the prospective employee was eligible to work. The Business Office Manager/HR Director stated Employee A completed her application to the facility on [DATE]. She said the results of her fingerprint and background screening were received on 12/28/22, and Employee A started orientation at the facility on 2/07/23. The Business Office Manager/HR Director explained that when she verified the professional license, using the license number provided by Employee A, nothing flagged, which indicated the license was clear and active. She recalled she also checked Employee A's Social Security (SS) card and recalled the name on the professional license and Employee A's driver's license were spelled differently, and the middle names/initials were different. She stated she did not compare the names on the professional license and the driver's license and did not ask Employee A about the different spelling of the names. The Business Office Manager/HR Director stated she did not notice the discrepancy then, and did not review all the required documents thoroughly prior to the hiring of Employee A. On 5/25/23 at 11:02 AM, the Director of Nursing (DON) stated she interviewed Employee A on 12/22/22. She said Employee A had good customer service, was very knowledgeable, and showed knowledge regarding the fundamentals of nursing. The DON recalled she reviewed Employee A's application, discussed where she went to school, but never reviewed her license/certificate. She said no one picked up on the discrepancy regarding the names on her driver's license, Social Security card, and the professional license. The DON noted Employee A had two days of orientation, beginning on 2/07/23 with shadowing and on 2/09/23 she was given an assignment with oversight from a preceptor. She said on 2/14/23, Employee A was on a medication cart by herself. The DON confirmed Employee A administered medications via gastrostomy tube, maintained gastrostomy tube feedings, and administered insulin injections and other oral and optic medications during the period she worked at the facility. On 5/25/23 at 11:24 AM, the Administrator stated employee A was already hired at the facility when she started, and she recalled she was made aware of the issues with the employee's license when the detective notified the facility on 5/03/23. The Administrator said employee A was already terminated due to absenteeism, and being late frequently. She stated the facility did not verify the spelling of the names on the documents provided by Employee A. On 5/25/23 at 11:28 AM, the Medical Director explained he was made aware of the Employee working at the facility as a LPN without a license when he attended a meeting with the Administrator, Regional Consultant Nurse, and the DON on 05/03/2023. He stated he was shocked, and was concerned if any resident was harmed. He said he was pleased the facility had assessed the residents by doing clinical reviews of records and interviews and also reviewing all transfers to the hospital that identified there was no harm done to the residents. The Medical Director stated he attended the Ad Hoc Quality Assurance Performance Improvement (QAPI) and agreed with steps taken to address the issue. He stated nurses usually paged him on his paging service, but he had no recollection of having any interaction with Employee A. Review of the job description for Administrator with revision date of 1/1/2015 revealed, the primary purpose of the Administrator was to direct the day-to-day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. The duties and responsibilities were to, Ensure that appropriate employment identification and work documents are presented prior to the employment of personnel and that appropriate documentation is filed in the employee's personnel record in accordance with current regulations mandating such documentation The job description for Human Resources Manager with revision date of 1/01/2015 read, The primary purpose of your position is to provide Human Resources in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as directed by the Administrator, to assure that quality personnel are interviewed, trained and employed Ensure hiring .procedures comply with established policies and procedures .Hire personnel in accordance with established hiring practices. Review of the job description for Director of Nursing Services with revision date of 1/1/2015 revealed, a part of the job duties and responsibilities was to Develop, maintain, and periodically update the written procedure for ensuring that professional nursing personnel, including private duty nurses, have valid and current licenses as required by this State Ensure that direct nursing care be provided by LPNs .qualified to perform the procedure Review of the corrective actions implemented by the facility revealed the following which were verified by the surveyor: Employee A was terminated on 3/07/23, and her last working day at the facility was 3/06/23. *On 5/03/23 the HR Director was notified via telephone by a detective from the criminal investigation division, that an investigation related to identity theft, and the accuracy of nursing license was initiated pertaining to Employee A. *On 5/03/23 the facility conducted an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting, and revealed the root cause(s) were, Identity theft, and that Employee A's driver's license, and level II background screen was not validated for accuracy of demographics. A Performance Improvement Plan (PIP) was initiated, objective and goal was, Services are provided by qualified personnel: Focused area: Licensed Nurse. *On 5/03/23 the facility initiated an investigation regarding validity Employee A's license. *Initiated investigation to ensure care and services were provided to residents the employee was assigned to. * Employee Record review conducted revealed Employee A worked from 2/07/23 to 3/06/23. Terminated on 3/07/23 for absence attendance, and tardiness. Verified absence of nursing license, Law enforcement notified, and Florida Department Of Health (FL DOH) reporting filed via practitioner complaint process. * Cross check for applicable employees holding a licensure/certification done to ensure: Licensed nurse/CNA/Therapist/ verification report retrieved from FL DOH website Nurses' professional license validated with driver's license and Level II background screen (BGS), verified by two employees (HR and Administrator/designee). *Current employees verified via employee roster, BGS clearinghouse website. *Residents currently in facility assessed by licensed nurse-(oversight by RN) any issues/concerns communicated to attending physician/family/responsible party *Resident interviews conducted with residents with Brief Interview for Mental Status (BIMS) score of 12 out of 15 or greater, skin checks conducted for those with BIMS 11 out of 15 and below to ensure facility was free from Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown source (ANEMMI). No concerns were noted. A BIMS score of 0 to 7 indicates severely impaired cognition, a score of 8 to 12 indicates moderately impaired cognition, a score of 13 to 15 indicates intact cognition. *Medication carts were reviewed to ensure narcotic counts correct; no concerns noted. *Comprehensive review of care and services carried out to include Risk management and AHCA federal reportable events from 2/07/23 to 3/07/23 reviewed to ensure there were no deviations from practice regarding: nursing care, reviewed falls, grievance log, concerns, hotline complaints, return to hospital, to ensure no deviation of practice. Resident representatives of residents' Employee A cared for were notified of unlicensed activity. *Licensed Nursing hours reviewed for days Employee A worked, hours for days identified removed. *Initiated education- Abuse, Neglect, Exploitation 138/139 staff educated, 100% completed on 5/05/23. *On 5/03/23 Abuse, Neglect, Exploitation (ANE) completed for residents in Employee A's assignment on 2/09/23, 2/14/23, 2/18/23, 2/19/23, 2/20/23, 2/24/23, 2/25/23, 2/26/23, 2/27/23, 3/04/23, 3/05/23, and 3/06/23 indicated no concerns, interviewed families of residents with BIMS below 10. *Conducted full house audit for ANE: to ensure no care concerns. Questions included: Do you have any safety concerns? Do you have any care concerns? Do you have any concerns or feel that you may have been neglected, abused, mistreated, exploited and/or misappropriation. *On 5/03/23 4 of 4 persons responsible for obtaining initial verification and ongoing monitoring of licensure and certification status re-educated on facility process for: validating License/Certification status/obtaining BGS and license verification with validation of demographics by two staff members for accuracy. Licensed nurse verification of demographic accuracy to be validated with (HR and administrator) for all active licensed nurses. *Licensed Nurse verification report validation with driver's license and level II BGS for validation of demographic accuracy to be validated with (HR and Administrator) for all active licensed nurses. *Systemic Changes: The facility initiated a cross-check process to include Onboarding- facility will determine and validate proper education, certification, licensing for positions applying for- by HR and director of hiring department. Obtain copy of driver's license/government issued ID, verify license through FL DOH Medical Quality Assurance (MQA) site and validate demographics accuracy on level II AHCA background clearing house, to be reviewed/validated by HR and Administrator and/or DON. *Beginning 5/03/23 the facility Administrator/designee reviewed concern/grievance log, 24/72 -hour report, resident/family council meetings, facility compliance /complaint line, risk management portal, electronic health record, alert reporting during the stand up/stand down administrative/clinical morning meetings. *On 5/04/23 an Immediate AHCA report was submitted. * SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress note for RNs/LPN/LVNs (Licensed Vocational Nurse) for all residents in Employee A's assignment evaluated by Licensed nurse, medical records reviewed with the Medical Director, plan of care reviewed- no changes in condition noted. Responsible parties made aware of unlicensed staff activity. * On 5/08/23 an additional Ad Hoc QAPI was held to review actions implemented. Review of the in-service attendance sheets revealed staff signatures to reflect participation in education on Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of unknown origin, and the importance of licensure/certification rules and regulations for applicable employees such as nursing/CNA/Therapist. Review of the audit titled, Licensed Nurse/Agency/Student/volunteer Log revealed the log would be utilized by the Human Resources Director/designee and Director of Nursing/designee to review photo identification, licensure/certification (if applicable) and Level II Background Screening/State specific background screening. The log indicated audits were conducted on 5/05/23 and 5/08/23, and all components were identified, and in compliance with required regulations and facility's policy and procedures. On 5/10/23, and 5/26/23, interviews were conducted with three Registered Nurses, five LPNs, three CNAs, three Rehab staff, one Receptionist, and one housekeeping staff, All verbalized understanding of the education provided. On 5/26/23, interviews were conducted with four of four people responsible for obtaining initial verification and ongoing monitoring of licensure and certification status. They verbalized understanding of the education provided. The surveyor determined based on the facility's corrective actions, the facility was in substantial compliance.