**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of facility documentation, review of personnel records and interviews with staff, it was determined that the facility failed to ensure six of six employees possessed the appropriate skills and competencies to provide nursing and related care and services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Further, review of Employee E21's personnel file revealed that the Employee E21 was an unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration as a nurse. This failure placed 63 residents who received care and services from Employee E21 at the facility, at risk of injury and/ or harm and resulted in an Immediate Jeopardy situation. (Employees E16, 17, 18, 19, 20 and 21). Findings Include: Review of the Professional Nursing Law The Act of [DATE] P.L 317, No 69, revealed that Section 3. Registered Nurse, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Use of Title and Abbreviation R.N., C.N.S. or C.R.N.A.; Credentials; Fraud.--(a) Any person who holds a license to practice professional nursing in this Commonwealth, or who is maintained on inactive status in accordance with section 11 of this act, shall have the right to use the titles nurse and registered nurse and the abbreviation R.N. No other person shall engage in the practice of professional nursing or use the titles nurse or registered nurse or the abbreviation R.N. to indicate that the person using the same is a registered nurse, except that the title nurse also may be used by a person licensed under the provisions of the act of [DATE] (1955 P.L.1211, No.376), known as the Practical Nurse Law. No person shall sell or fraudulently obtain or fraudulently furnish any nursing diploma, license, record, or registration or aid or abet therein. (b) An individual who holds a license to practice professional nursing in this Commonwealth who meets the requirements under sections 6.2 and 8.5 of this act to be a clinical nurse specialist shall have the right to use the title clinical nurse specialist and the abbreviation C.N.S. No other person shall have that right. Review of job description for Registered Nurse (RN) revised on [DATE], revealed that Education and Experience Requirements: Current state professional nursing license, one to two years' experience, geriatric/long term care experience preferred, maintain or able to obtain current CPR certification. Job accountabilities. 1. Plan, directs and provides resident care according to physician orders and the interdisciplinary plan of care. 2. Communicates changes in resident's condition in a timely fashion to include but not limited to physicians, other disciplines, the following shift, and family members. 3. Administer medications, treatments in compliance with federal, state and local laws and with the community policies and procedures. 6. Performs venipuncture to obtain blood. Further review of job description for Registered Nurse revealed that skills and competencies are required for the job accountabilities including; Administering medications and treatments, performs venipuncture to obtain blood specimens according to community practice, use of standard precautions to prevent spread of communicable disease, enforces and trains proper infection control practices to team members, exhibits knowledge of and effectively executes disaster plans and communicates changes in residents' condition in a timely fashion to include but not limited to the RN, physician other disciplines the following shift and family members. Review of a blank facility competency evaluation form indicated that the facility developed a competency evaluation program with performance indicators to ensure that the nurses including RNs and LPNs have the competency to perform necessary job accountabilities which indicated if a job function are met or not met. Review of facility documentation dated February 2, 2024, revealed that A concern was brought to this NHA (Administrator) on February 2, 2024, at approximately 10:13 am regarding a licensure investigation for an employee of Cathedral Village. Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents. Further review of the documentation revealed that upon hire Employee E21, Registered Nurse, presented a registered nursing license with the name (First name Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. The individual (RN) remained on administrative leave while facility conducted investigation and did not submit any further documentation. Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included a name with three parts, last name included two parts). License was verified under a similar name (but only had two parts to the name, last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a name that has three parts. Employee 21's name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy in the name. A request for competency evaluation for Employee E21 was requested from the Nursing Home Administrator on [DATE] at 2:17 p.m. Facility did not provide evidence of competency evaluation for Employee E21. Review of Employee E21's personnel file revealed that the employee was offered the job as an RN with a hire date of [DATE]. Further review of the personal file revealed that the employee worked in the facility as an RN until February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN. Continued review of Employee E21's personnel file did not include any verifiable nursing or any related education. Personnel files did not include any competency evaluation form. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 administered medications to residents including anxiolytics, antihypertensive, antipsychotics, Parkinson's medications, antidepressants, anticonvulsants, anticoagulant, antibiotics, diuretics, beta blockers (slows heart rate, treat chest pain), anti-diabetic medication, steroids, antiviral medications, which require monitoring of side effects. Review of clinical record also revealed that Employee E21 administered resident complex resident assessment which needed specialized skills and competencies including wound care, neurological assessments, administered insulin, admission assessments, skin assessments change of condition assessments and PICC line assessments. There was no documentation available to review to determine that facility ensured Employee E21 was competent in performing these services. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift. A review of the facility record revealed that the facility had one resident with PICC line/Midline catheter who received treatment and care from the staff such as dressing change, medication and fluid administration, site assessment and monitoring. Interview with the Director of Nursing (DON) on [DATE], at 11:00 a.m. stated nursing staff provided care for residents with PICC lines and midline. A review of the facility record revealed that the facility had residents with pressure ulcers (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin.) and other wounds who received care and services from staff such as dressing change and wound assessment. A request for the evidence of PICC line/midline/ IV care and wound care staff competencies or annual evaluations of additional 5 selected licensed and registered nurses, Employee E16, 17, 18, 19, 20 were made to the Nursing Home Administrator and Director of nursing on April Facility was not able to provide evidence of PICC line/midline/ IV care and wound care staff competencies or annual evaluations of 5 selected licensed and registered nurses. During an interview on [DATE], at 11:30 a.m. the Nursing Home Administrator confirmed that the nursing staff competencies or annual evaluations related to PICC line/midline/ IV care and wound care was not completed for the nursing staff in the past year. The Nursing Home Administrator also confirmed that the facility did not have a process of competency evaluation. The Nursing Home Administrator stated facility has a competency evaluation program developed to evaluate the competencies of the nurse but the facility did not implement the program for the nurses. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 4:00 p.m. for the facility's failure to ensure that Employee E21, (unlicensed staff who provided care and services as a Registered Nurse without verifiable educational background as a nurse) possessed appropriate skill sets and competencies to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident This failure placed 63 residents who received care and services from Employee E21 at the facility at risk of injury and or harm and resulted in an immediate jeopardy situation. The facility submitted a written plan of action on [DATE], at 9:00 p.m. and implemented the plan of action which included: Employee A was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses will be informed on [DATE]. Legal counsel notified that state's Attorney General is involved. An electronic health record audit was completed on [DATE] by the Nursing Home Administrator or designee to review residents who may have received care or treatment from Employee E21. Current residents identified from this audit will be interviewed by a Licensed Nurse and Social Worker. This inquiry will include a statement from the individual related to medication administration, evaluations and assessments, wound care, and general care and nursing services provided was completed [DATE]. A physical head to toe skin evaluation of the residents in the assignments of Employee E21 was completed on [DATE]- [DATE]. An audit was conducted by the Human Resource Department to ensure that licensed staff have a skills competency completed and present in their employee file within the last year on [DATE]. Any licensed staff identified not to have had skills competency completed will have the competency completed prior to their next scheduled shift; all staff completed by [DATE]. An audit was completed by human resource department on current licensed nurses employed by PSL (Presbyterian Senior Living) at the community to ensure compliance with licensure verification on [DATE], no variances identified. The human resource department team members at the community were re-educated on new hire/pre- employment processes for licensed staff by the [NAME] President of Employee Relations or designee on [DATE]. The Human Resource department team members at the community were re-educated by the [NAME] President of Employee Relations or designee on- the requirement to ensure that all licensed staff have a current skill competency checklist completed at new hire during the orientation period and then annually in their employee file to ensure that all licensed staff possess competencies, education, and license as applicable to provide nursing care, all staff completed by. [DATE]. On [DATE], at 11:40 a.m. the action plan was reviewed, personell records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed. The Immediate Jeopardy was lifted on [DATE], at 11:40 a.m. Refer to F839 28 Pa. Code 201.14 (a)(b) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(e)(1)(2) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of facility documentation, review of personal records and interviews with staff, it was determined that the facility failed to ensure that a professional staff possessed required nursing license in accordance with applicable state law. Review of one of six personnel files revealed that Employee E21, who was an unlicensed staff, and provided care as a Registered Nurse, to 63 residents. Employee E21 did not have a verifiable educational background and registration, as a Registered Nurse. This failure resulted in an Immediate Jeopardy situation to 63 residents who received care and services from Employee E21. (Employee E21). Findings Include: Review of the Professional Nursing Law The Act of [DATE] P.L 317, No 69, revealed that Section 3. Registered Nurse, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist, Use of Title and Abbreviation R.N., C.N.S. or C.R.N.A.; Credentials; Fraud.--(a) Any person who holds a license to practice professional nursing in this Commonwealth, or who is maintained on inactive status in accordance with section 11 of this act, shall have the right to use the titles nurse and registered nurse and the abbreviation R.N. No other person shall engage in the practice of professional nursing or use the titles nurse or registered nurse or the abbreviation R.N. to indicate that the person using the same is a registered nurse, except that the title nurse also may be used by a person licensed under the provisions of the act of [DATE] (1955 P.L.1211, No.376), known as the Practical Nurse Law. No person shall sell or fraudulently obtain or fraudulently furnish any nursing diploma, license, record, or registration or aid or abet therein. (b) An individual who holds a license to practice professional nursing in this Commonwealth who meets the requirements under sections 6.2 and 8.5 of this act to be a clinical nurse specialist shall have the right to use the title clinical nurse specialist and the abbreviation C.N.S. No other person shall have that right. Review of job description for Registered Nurse revised on [DATE], revealed that Education and Experience Requirements: Current state professional nursing license, one to two years' experience, geriatric/long term care experience preferred, maintain or able to obtain current CPR certification. Job accountabilities. 1. Plan, directs and provides resident care according to physician orders and the interdisciplinary plan of care. 2. Communicates changes in resident's condition in a timely fashion to include but not limited to physicians, other disciplines, the following shift, and family members. 3. Administer medications, treatments in compliance with federal, state and local laws and with the community policies and procedures. 6. Performs venipuncture to obtain blood Review of facility information dated February 2, 2024, revealed that A concern was brought to this NHA(Nursing Home Administrator) on February 2, 2024, at approximately 10:13 a.m. regarding a licensure investigation .Currently this employee is not working in the building. Cathedral Village has reached out to this employee for more details and clarification. Employee informed us that she will provide required documents. Further review of the documentation revealed that upon hire on [DATE], Employee E21, presented a Registered Nurse's license with the name (First name and Last name). This license was active on the hire date, and the licensure status was also verified and found to be in good standing. Continued review of the documentation revealed that background checks including criminal history were verified under Employee E21's real name (which included first name and last name which had two parts). The Registered nurse license was verified under a similar name (but only the last name with only one part) as this was the name provided on the nursing license she presented. Both Social security card and driver's license were presented with a last name that had two parts. Employee 21's last name on the identification document provided was different from the RN license. There was no documentation available to indicate if the facility human resource or other facility staff clarified the discrepancy with Employee E21's last name. Interview with previous facility Nursing Home Administrator (Administrator at the time of the alleged incident), on [DATE], at 2:00 p.m. stated Employee E21 provided a fraudulent RN license by obtaining identity of another person with similar name. Facility did not follow up on the discrepancy between the name provided and the name on the license. Facility also did not ask the employee to provide the copy of the license issues by the state to the individual who possessed the license. Facility only verified and kept copy of the license which was available online to the public. She confirmed that the Employee E21 obtained identity of another individual who possessed a RN license with similar name and worked in the facility for 4 months and provided care to the residents including medication administration and licensed/registered nurse's assignments. Review of Employee E21's personal file revealed that the employee was offered the job as an RN with a hire date of [DATE]. Further review of the personal filed file revealed that the employee worked in the facility as an RN till February 1, 2024. Employee worked 30 shifts as an RN, which 23 of the 30 shift she worked independently providing all responsibilities as an RN. Continued review of Employee E21's personal file did not include any verifiable nursing or any related education. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 administered medications to residents including anxiolytics, antihypertensive, antipsychotics, Parkinson's medications, antidepressants, anticonvulsants, anticoagulant, antibiotics, diuretics, beta blockers (slows heart rate, treat chest pain), anti-diabetic medication, steroids, antiviral medications, which require monitoring of side effects. Review of clinical record also revealed that Employee E21 administered resident complex resident assessment which needed specialized skills and competencies including wound care, neurological assessments, administered insulin, admission assessments, skin assessments change of condition assessments and PICC line assessments. There was no documentation available to review to determine that facility ensured Employee E 21 was competent in performing these services. Review of facility documentation from [DATE], to February 24, 2024, revealed that Employee E21 provided care and services in the capacity of a registered nurse to 63 residents over 30 shifts. Employee E21 provided care to approximately 20 residents per shift. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 4:00 p.m. for the facility's failure to ensure that professional staff possessed requited licenses or registration in accordance with applicable state law. This failure resulted in Employee E21, unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration, as a nurse and placed 63 residents at the facility at risk of injury and or harm and resulted in an Immediate jeopardy situation. The facility submitted a written plan of action on [DATE], at 9:00 p.m. and implemented the plan of action which included: Employee 21 was immediately removed from the schedule and placed on administrative leave. Incident reported to local police department and Department of Health in accordance to local and state laws. Legal counsel notified of multi state and identity theft investigations and agencies informed. Department of State who issues licenses who be informed [DATE]. Legal counsel notified that state's Attorney General is involved. An audit was completed by human resource department on current licensed nurses employed by PSL at the community to ensure compliance with licensure verification as applicable according to the job description and state laws on [DATE]. All licensed staff after the initial audit have also been audited by the Human Resource department prior to employment. The policy for employee onboarding process was updated and revised on [DATE] to ensure licensed staff are appropriately licensed and educated as applicable according to the job description and state laws. The Human Resource department team members at the community were re-educated by the [NAME] President of Employee Relations or designee on the updated policy on [DATE]. All licensed staff after the initial audit which was completed on [DATE] have also been audited by the Human Resource department prior to employment. Audits started [DATE] no concerns identified and will continue to be completed biweekly according to new employee orientation schedule. Audits will continue to be going forward. On [DATE], at 11:40 a.m. the action plan was reviewed, personal records were reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility audits were reviewed. The Immediate Jeopardy was lifted on [DATE], at 11:40 a.m. 28 Pa. Code 201.14 (a)(b) Responsibility of licensee 28 Pa. Code: 201.18 (b)(1)(e)(1)(2) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services