Jay Hospital

“SPECIAL REQUIREMENTS FOR CAH PROVIDERS LTC CFR(s): A CAH must meet the following requirements in order to be granted an approval from CMS to provide post-CAH SNF care, as specified in §409.30 of this chapter, and to be paid for SNF-level services, in accordance with paragraph (c) of this section. This Condition is not met as evidenced by: 39374 Based on interviews, record reviews, and reviews of facility policies and procedures the facility failed to protect patients’ rights to privacy when protected health information including patients’ first and last names and medical conditions were entered into an artificial intelligence (AI) app and photographs were taken of patients which were shared electronically using an app known as Snapchat. The facility failed to protect patients’ right to be free from abuse and harassment when photographic images and AI-generated songs of a derogatory and humiliating nature, depicting patients in various stages of dress were shared among staff members. The images and songs were reported to have existed on the personal cell phones of staff members and the exact extent to which they may have been shared outside of the facility is not known. The rural, small community in which the facility is located and news media surrounding the events have contributed to the psychosocial impact of the breaches in privacy and psychosocial harm experienced by patients affected by the facility’s actions. These events involved 4 of 4 patients sampled (#1, #2, #3, and #4) who were admitted to the hospital for skilled nursing services and are estimated to have occurred between December 1, 2024, and September, 2025. Cross-reference C1608 and C1612.”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39374 Based on interviews, record reviews, and reviews of facility policies and procedures, the facility failed to protect patients’ rights to privacy when protected health information including patients’ first and last names and medical conditions were entered into an artificial intelligence (AI) app and photographs were taken of patients which were shared electronically using an app known as Snapchat. The facility failed to protect patients’ right to be free from abuse and harassment when photographic images and AI-generated songs of a derogatory and humiliating nature, depicting patients in various stages of dress were shared among staff members. The images and songs were reported to have existed on the personal cell phones of staff members and the exact extent to which they may have been shared outside of the facility is not known. These events involved 3 of 4 patients sampled ( #2, #3, and #4) and are estimated to have occurred between December, 2024, and September, 2025. Cross-reference C2521 and C2525.”

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 39374 Based on interviews, record reviews, and policy reviews, the facility failed to safeguard patient privacy when staff members entered protected patient information including first and last names and medical conditions or descriptions of patient conditions into an artificial intelligence (AI) app to create humiliating and derogatory songs affecting 4 of 4 patients sampled (Patients #1, #2, #3, and #4) who were admitted to the facility for skilled nursing services. (Cross reference C2521) The findings include: On 10/13/2025 at 3:30pm, a telephone interview with registered nurse (RN) I took place related to staff taking and showing photos of patients. RN I said at sometime in July 2025, another registered nurse working at the facility, RN B, used her personal cell phone to display photos of Patient #4. During the conversation with her coworkers, RN I was told that Patient #4 had passed away, and RN I guessed the photo was taken during Patient #4’s last admission to the facility. RN I described the photo as a picture of Patient #4 taken from a remote patient monitoring screen. RN I described Patient #4 as “not alert and oriented” and for this reason a remote patient monitoring system was in use during her stay. Remote patient monitoring enables video observance of a patient displayed on a computer screen at the nurses’ station to monitor patients at risk for fall or injury. RN I described the photo of Patient #4 as being a picture of the remote patient monitoring screen, showing Patient #4 laying in bed with a gown on and pulled up so that only her breasts were covered. The photo was described as “you could kind of see her vaginal area, her belly and her legs and feet in the photo.” RN I explained that Patient #4’s head was turned, and it was not possible to know if she was awake or asleep. RN I described that, while showing the picture of Patient #4, RN B was joking about Patient #4’s body and how “she kept spitting everywhere.” RN I explained the conversation with RN B took place at work in the charting room and another registered nurse, RN C, showed a photo on her cell phone of Patient #2, a female patient with an above the knee amputation. The photo showed Patient #2 sitting up at the edge of the bed and looked like it was taken from close up. RN I described that Patient #2’s body was covered in the photo except for her right foot and her face. RN C and RN B were making jokes about Patient #2 and described the picture as trying to help her because she was straddling the trash can to urinate. RN I described that the photo of Patient #2 was not a picture from the remote monitoring system screen and that it was not clear if the photo was on a Snapchat app or taken with the camera on the phone. RN I said no other photos were shown that night but was aware of another photo sent by RN C using the Snapchat app which showed a photo of Patient #1. The photo of Patient #1 was described as a picture of Patient #1’s face taken from a photo on Facebook and pasted onto a bikini body. RN I confirmed there were a “few other nurses” present who saw the photos and this was a violation of patient privacy and that the policy instructs staff are “not even to take selfies because patient privacy and information can be leaked and they go over these things in our policy.” RN I continued by saying “I don’t know if you’re aware of the songs that were made using an AI (artificial intelligence) generated app that RN C and RN B were using with their names, certain medical conditions, and other things of that nature. I don’t know if it was posted or shared, but they were on their personal devices. This was around the time that I saw the photos. Patient #4 was one, and it contained her name and was about the fact that she spits up a lot of the time and the song was called ‘peanut butter phlegm’ because that’s what she coughed up. There were others, one about Patient #2, it said, ‘her leg is rotten’ and it’s about her diabetes and talked about her medical condition with her legs. There was one mentioning Patient #3. He had an enlarged scrotum, so it referred to ‘his big balls.’ These songs were played in the charting room, RN C and RN B both had them on their phones. RN C showed them to me on her app and RN B talked about them being on her phone, too. Not sure what the app is but it is an AI generated app. I don’t know if its like an Instagram where you can post, I’m not sure.” On 10/14/2025 at 8:15am, a telephone interview took place with patient care technician (PCT) F who denied seeing any photos of patients. PCT F confirmed being aware that RN A, RN B, RN C, and PCT D were terminated from their positions related to allegedly taking or sharing photos of patients. PCT F described being interviewed during the facility investigation of the incident and said, “In the interview I told them I heard the song come from one of the girls’ phones about a patient and I knew they had used it to take pictures of other employees. I can’t remember exactly, but I remember a name from the song, it was Patient #4 and had something to do with peanut butter phlegm. I don’t know what they were trying to be.” PCT F said she was familiar with Patient #4 and described her as kind, said “I loved her” and that she needed a bit more assistance than others. She needed one to two employees to help her get around and sat in her recliner and was elderly; she’d been a patient at the hospital a few times. During an interview on 10/14/2025 at 8:45am, RN E explained that RN B took a picture of him providing care to Patient #4. RN E described the photo as showing him standing over Patient #4 and placing a blanket on her, the photo was taken from behind and then shown to RN E by RN B. RN E explained that he worked on the unit with RN B from October 2024 to around January-February 2025 and while he was not aware of the exact date, it was during that time the photo was taken and shown to him and that he told RN B to delete it. RN E said “they teased me about being her boyfriend and I got along with her well so they would move me and change my patient load, so I had her. I told them during my interview I swapped from their shift to the other shift just to get away from them to be honest and one night they were talking about making a song and adding Patient #4 to it and they were singing it, talking about how it would go. I never saw it, and I said they shouldn’t do that. The staff members were RN A, RN B, RN C, and PCT D was probably there because she was the unit coordinator at the time. There wasn’t anything about photos at the time. It’s out in the media now and there were other behaviors, staff to staff, but not staff to patient that I’m aware of.” RN E continued to describe the staff behavior by saying, “I feel like everybody had heard rumors and knew what was going on but the main three were RN A, RN B, and RN C and I know that RN B and RN C took pictures of me and Patient #4. I don’t have any proof of what I’ve seen.” In response to whether this behavior violated policies or patient rights, RN E remarked, “Yeah, that’s common sense. That includes HIPAA (Health Information Portability and Accountability Act, a federal law that establishes standards to protect sensitive health information from disclosure without patient consent according to www.hhs.gov) policies, not having your cell phone out at work is probably a policy as well; common sense, HIPAA, patient rights, just being a good person.” On 10/14/2025 at 11:00am, an interview with registered nurse (RN) L took place in which she described that a staff member came to her to report an incident of a patient being photographed. The staff member explained to RN L there “had been a Snapchat thread going between several people and some patients. They had taken a picture of a patient and used AI to manipulate it and put little sayings on it. They took AI and made a song with patients’ first and last names on it. And, when a patient was on ‘Careview’ (the remote patient monitoring system) that the PCT at the desk watches on the screen, a picture was taken of them and said the patient was partially unclothed. The staff member had a picture of the AI and showed me, and I knew the patient.” RN L said she had the staff member provide a list of names of everyone who was involved and who had seen it on someone else’s device. RN L was able to confirm the name of the patient in the picture was Patient #1 and described that when Patient #1 is a patient in the hospital, “she doesn’t wear a gown, she wears her own clothes. You could tell the picture was taken through a window of Patient #1 outside going through her car and she had on sweatpants, lavender, and some type of t-shirt. I couldn’t tell if she was a patient at the time the picture was taken, but I knew she was on hospital grounds because her car was parked in the parking lot next to the ER. The picture they took of her at the car was the back of her, but somehow, they had manipulated another picture that showed her face with sunglasses on and some type of meme. It was two different poses but one picture, it showed her from afar from the back side and then her face from the chest up with sunglasses on.” RN L continued with the description of the employee behavior that was reported to her as one of the jingles made up included a reference to Patient #3 and “they were talking about his ‘rotten balls.’ Whenever Patient #3 was admitted to the hospital, he is always CHF (congestive heart failure); he always has edema (swelling) and one time when he was there, he had a lot of scrotum edema.” RN L explained that Staff K and Staff M told her they were gathering information and there was an active investigation and asked her not to discuss it. She recalled that sometime in September (2025) when she learned staff involved had been placed on administrative leave and that they might need her to work extra. She described this as possibly around five weeks after she became aware of the allegations and that a total of five people were placed on administrative leave. During an interview on 10/13/2025 at 4:26pm, the RM director explained the (facility’s) attorneys have advised that Staff M (the facility’s compliance officer who investigated the allegations) and Staff K (the facility human resource representative who investigated the allegations) were advised not to speak to the surveyor. In a follow up interview with the RM director on 10/14/2025 at 12:04pm, the RM director explained she spoke with Staff M and he said he was not aware of Patient #4 and that when staff talked about Patient #4 in interviews he conducted, he thought they were talking about Patient #1. A record review for Patient #4 confirmed the last inpatient admission for Patient #4 occurred on January 19, 2025. The orders for the admission on January 19, 2025, did not include orders for remote patient monitoring. Patient #4 was discharged to a skilled nursing facility on January 25, 2025. The record confirmed that RN B, RN C, RN E, and RN I were staff involved with Patient #4’s care during the admission from January 19-25, 2025. Patient #4’s record showed admissions to the facility on 12/16/2024 for inpatient acute care, an admission on 11/26/2024 for a swing-bed (skilled nursing services) admission, and an admission on 11/18/2024 for inpatient acute care. Reviews of the orders for each of these admissions revealed that only the swing-bed admission on 11/26/2024 included an order for “safety sitter” initiated on 12/01/2024 and discontinued on 12/12/2024 which documented “criteria fall risk. Sitter type: virtual.” The virtual order indicated remote patient monitoring was used. Patient #4 was discharged on 12/12/2024 with discharge diagnoses documented which included decreased activities of daily living, diabetes, dependence on oxygen, COPD (chronic obstructive pulmonary disease), dysphagia, decreased IADLs (instrumental activities of daily living, this includes tasks such as cooking and managing finances), obesity related hyperventilation syndrome, chronic panniculitis with candidiasis. On 12/16/2024, Patient #4 was readmitted to the facility for inpatient acute care with an admitting diagnosis of CHF (congestive heart failure) and pneumonia and was discharged on 12/19/2024 with a discharge diagnosis of CHF. An interview with the RM director on 10/14/2025 at 12:30pm during the review of Patient #4’s medical record included pointing out that since Patient #4 was last admitted to the facility in January, the evidence of the activity involving violation of patients’ rights may have begun earlier than the February time frame reported by the facility. Based on the descriptions of the photo depicting Patient #4 being taken from the screen where staff observe patients who have remote patient monitoring ordered, the record review suggests the timeframe when this photo could have been taken was between 12/1/2024 and 12/12/2024. The record review confirmed that RN B was involved with Patient #4’s admission which began on 11/26/2024 and included the use of the remote monitoring system. A record review for Patient #1 included only one inpatient admission which began on 2/10/2025 and was a swing-bed admission. The record described Patient #1 as having a below the knee amputation of the right lower extremity and in need of post op (after surgery) pain management, wound management, physical therapy, occupational therapy, speech therapy to evaluate for aspiration risk and strength her weak legs, as well as monitoring her multiple medical problems including very brittle diabetes mellitus type 1, dysautonomia, chronic back pain, hypothyroidism; history of multiple surgeries, including pancreatic transplant x2. Patient #1 was discharged to skilled nursing on 2/22/2025. Nurses involved in the care of Patient #1 during this admission included RN A, RN B, RN E, and RN L. A review of Patient #3’s record included an acute inpatient admission on 11/08/2024, a swing bed admission on 12/27/2024, a swing-bed admission on 2/3/2025, a swing bed admission on 3/26/2025, and a swing bed admission on 5/19/2025. The admission on 12/27/2024 documented an admission diagnosis for endocarditis with a discharge on 1/24/2024 to another hospital which documented “Patient to be discharged from skilled care and taken to the ER (emergency department) for evaluation of worsening CHF manifestation, worsening diabetic foot ulcer, and severe scrotal edema.” There were no orders for a sitter during this admission. Staff involved in the care of the patient during this admission included: RN H, RN I, RN J, PCT G, RN L, RN C, and PCT F. The admission on 2/3/2025 had an admitting diagnosis of wound of foot. The history of present illness (HPI) for the 2/3/2025 admission noted “patient admitted to (another facility) on 1/25/2025 with a chief complaint of CHF exacerbation manifested by extreme scrotal edema and evaluation of nonhealing right foot wound. The ultrasound showed marked scrotal wall thickening. ...He is transferred back to (subject facility) for SNF (skilled nursing facility) care, mostly in the form of wound care right foot. He has been in the hospital for the past 6 weeks.” Patient #3 was discharged on 2/28/2025 to home health. There was no remote patient monitoring ordered during the admission. The nurses involved in Patient #3’s care during the 2/3/2025 swing-bed admission included RN A, RN B, RN C, RN I, and RN E. The admission on 3/26/2025 described the admitting diagnosis as history of hypoglycemia and a discharge date of 4/4/2025 to home health services. The discharge diagnoses included chronic systolic CHF, weakness, chronic kidney disease, diabetic wounds bilateral (both) feet. There were no sitter orders during this visit. The admission note documented “Patient with a multitude chronic health problems, most troublesome is chronic ischemic systolic CHF, also type 2 diabetes mellitus on insulin, stage 3 chronic renal failure, chronic bilateral feet wounds and chronic neck and low back pain. Has basically been in the hospital since 11/2024.” Staff involved with this admission included RN H, PCT F, RN L, RN J, and PCT G. Another Swing bed admission on 5/19/2025 included admitting diagnoses of CHF Exacerbation, pelvic fracture, physical therapy/occupational therapy (PT/OT). Patient #3 was discharged on 5/28/2025 to home health services with discharge diagnoses of Right Pelvic Fracture, chronic systolic CHF, Chronic diabetic wounds of feet. There were no sitter services ordered during this admission. Staff involved in this admission included: RN H, RN E, PCT G, RN J, PCT F. A record review for Patient #2 included an acute care inpatient admission on 2/6/2025, a swing-bed admission on 5/13/2025, a swing-bed admission on 6/23/2025, and a swing-bed admission on 7/16/2025. The admission on 2/6/2025 described an admitting diagnosis of cellulitis great toe left foot and diabetic foot wound with pain to the great left toe for two weeks with drainage around the toenail. There was no remote monitoring ordered during this admission and Patient #2 was discharged to another hospital on 2/12/2025. Nurses involved in this admission included RN A, RN L, RN B, and RN I. Patient #2 had a swing-bed admission on 7/16/2025 with an admitting diagnosis of gangrene following a Chopart amputation to the right foot (a type of amputation that removes part of the foot). Patient #2 was discharged to another hospital on 8/7/2025. Nurses involved in this admission included RN I, RN E, RN B, RN L, and RN C. Patient #2 had a swing bed admission on 6/23/2025 with an admission diagnosis of right trans metatarsal (foot) amputation. Patient #2 was discharged on 7/8/2025 to another hospital with a discharge diagnosis of gangrene on the right foot and severe peripheral artery disease. No sitter services were ordered during this admission. The admission note documented “patient in need of wound care, pain management, and continued antibiotics. She has known peripheral arterial disease with a history of systolic congestive heart failure with ejection fraction of 36%, peripheral arterial disease with a previous admission for nonhealing left great toe wound requiring amputation 4/23/2025 and later requiring an above the knee amputation on 5/02/2025, due to severe stenosis with no options for revascularization at that time. Patient subsequently developed gangrene involving her right great toe, and right 4th toe, and extending over to other parts of her foot resulting in the aforementioned transmetatarsal amputation 6/15/2025.” Staff involved in this admission included: RN B, PCT G, RN C, RN A, PCY F, and RN J. Patient #2 had an admission on 5/13/2025 with an admitting diagnosis of “above the knee amputation of left lower extremity.” She was discharged on 6/13/2025 with a discharge diagnosis of “Gangrenous toe.” There were no sitter orders during this admission. The admission note described “after reaching maximum acute care hospital benefit at (another) hospital 4/25/2025 through 5/13/2025 with patient having severe peripheral arterial disease, status post angioplasty (a procedure to open locked or narrowed arteries), and stent to the left superior femoral (upper leg/thigh) artery and popliteal (knee) arteries, with patient undergoing above-the-knee amputation on the left lower extremity, and is now battling gangrenous changes involving the right lower extremity.” Staff involved in this admission included: RN E, RN H, RN C, PCT F, RN A, RN B, PCT G, and RN L. A review of the facility’s Code of Conduct included a description on page 10 concerning the value of protecting private information and documented “We protect private and confidential information. Those whom we serve trust that we will protect the information provided to us including their health information and personal information.” The Code of Conduct included direction to staff that “Posting protected health information or photographs on a web site, social media page or public forum is strictly prohibited, even if the patient/client is not identified. We do not use our personal devices to text or transmit protected health information for any reason unless otherwise allowed by (facility) policy. We do not take or transmit photographs of those to whom we provide services except as required within our policies.” The facility provided information confirming the title, hire date and training completions for RN I, RN B, RN C, RN A, PCT D, and RN E which confirmed that all staff members received training on basic healthcare information, the facility Code of Conduct, HIPAA, and mandatory incident reporting within the past calendar year of the date of the survey. The hire dates for the staff are as follows: RN A - 2/24/2020 RN B - 6/1/2021 RN C - 3/20/2023 PCT D - 10/02/2017 RN E - 8/21/2023 RN I - 7/31/2024 A policy titled “Comprehensive Filming” with an effective date of November 2024 was reviewed and included a statement of purpose as “to provide standards on how to identify when recordings, films or other images of patients and Workforce Members are allowed, and to establish procedures to protect patient and workforce safety and privacy during the same.” The policy was stated as “consistent with its respect for patient and Workforce Member privacy and confidentiality, (the facility) will obtain appropriate permission and consent to Film patients, visitors, and Workforce Members ...v. Filming of any patient care treatment or procedure is prohibited, except as otherwise allowed below.” The policy described the specific exceptions which would allow filming within the facility and the consents required in order to allow filming. The policy included a statement that “all filming where patient or Workforce Member consent is required, the following apply: a. Individuals being filmed must be informed of the nature and proposed purpose of the filming and of its intended use.” Review of a pamphlet titled “A Nurse’s Guide to the Use of Social Media,” published by the National Council on State Boards of Nursing and accessed at https://floridasnursing.gov/forms/nurse-guide-social-media-info.pdf on 10/25/2025 at 10:31am, provided a standard for nurses regarding the use of social media outside of the work setting and using personal electronic devices such as cell phones related to patient interactions. The pamphlet explained “Privacy relates to the patient’s expectation and right to be treated with dignity and respect. Effective nurse/patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Patients will be hesitant to disclose personal information if they fear it will be disseminated beyond those who have a legitimate ‘need to know.’ Any breach of this trust, even inadvertent, damages the nurse/patient relationship and the general trustworthiness of the profession of nursing.” The pamphlet described “Examples may include comments in which patients are described with enough sufficient detail to be identified, referring to patients in a degrading or demeaning manner, or posting videos or photos of patients.””

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is 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. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 39374 Based on interviews, record reviews and review of facility documents, the facility failed to prevent abuse or harassment of 4 of 4 patients sampled (#1, #2, #3, and #4) who were admitted to the facility for skilled nursing services. The patients were photographed by hospital staff members and/or had their private patient information, including first and last names and medical conditions entered into an artificial intelligence (AI) app which generates songs. The evidence indicated the duration of the failure to protect patients’ right to be free from abuse and harassment began as early as December 1, 2024 and continued through approximately September, 2025. (Cross reference C2525) The findings include: On 10/13/2025 at 3:30pm, a telephone interview with registered nurse (RN) I took place related to staff taking and showing photos of patients. RN I said at sometime in July 2025, another registered nurse working at the facility, RN B, used her personal cell phone to display photos of Patient #4. During the conversation with her coworkers, RN I was told that Patient #4 had passed away, and RN I guessed the photo was taken during Patient #4’s last admission to the facility. RN I described the photo as a picture of Patient #4 taken from a remote patient monitoring screen. RN I described Patient #4 as “not alert and oriented” and for this reason a remote patient monitoring system was in use during her stay. Remote patient monitoring enables video observance of a patient displayed on a computer screen at the nurses’ station to monitor patients at risk for fall or injury. RN I described the photo of Patient #4 as being a picture of the remote patient monitoring screen, showing Patient #4 laying in bed with a gown on and pulled up so that only her breasts were covered. The photo was described as “you could kind of see her vaginal area, her belly and her legs and feet in the photo.” RN I explained that Patient #4’s head was turned, and it was not possible to know if she was awake or asleep. RN I described that, while showing the picture of Patient #4, RN B was joking about Patient #4’s body and how “she kept spitting everywhere.” RN I explained the conversation with RN B took place at work in the charting room and another registered nurse, RN C, showed a photo on her cell phone of Patient #2, a female patient with an above the knee amputation. The photo showed Patient #2 sitting up at the edge of the bed and looked like it was taken from close up. RN I described that Patient #2’s body was covered in the photo except for her right foot and her face. RN C and RN B were making jokes about Patient #2 and described the picture as trying to help her because she was straddling the trash can to urinate. RN I described that the photo of Patient #2 was not a picture from the remote monitoring system screen and that it was not clear if the photo was on a Snapchat app or taken with the camera on the phone. RN I said no other photos were shown that night but was aware of another photo sent by RN C using the Snapchat app which showed a photo of Patient #1. The photo of Patient #1 was described as a picture of Patient #1’s face taken from a photo on Facebook and pasted onto a bikini body. RN I confirmed there were a “few other nurses” present who saw the photos and this was a violation of patient privacy and that the policy instructs staff are “not even to take selfies because patient privacy and information can be leaked and they go over these things in our policy.” RN I continued by saying “I don’t know if you’re aware of the songs that were made using an AI (artificial intelligence) generated app that RN C and RN B were using with their names, certain medical conditions, and other things of that nature. I don’t know if it was posted or shared, but they were on their personal devices. This was around the time that I saw the photos. Patient #4 was one, and it contained her name and was about the fact that she spits up a lot of the time and the song was called ‘peanut butter phlegm’ because that’s what she coughed up. There were others, one about Patient #2, it said, ‘her leg is rotten’ and it’s about her diabetes and talked about her medical condition with her legs. There was one mentioning Patient #3. He had an enlarged scrotum, so it referred to ‘his big balls.’ These songs were played in the charting room, RN C and RN B both had them on their phones. RN C showed them to me on her app and RN B talked about them being on her phone, too. Not sure what the app is but it is an AI generated app. I don’t know if its like an Instagram where you can post, I’m not sure.” On 10/14/2025 at 8:15am, a telephone interview took place with patient care technician (PCT) F who denied seeing any photos of patients. PCT F confirmed being aware that RN A, RN B, RN C, and PCT D were terminated from their positions related to allegedly taking or sharing photos of patients. PCT F described being interviewed during the facility investigation of the incident and said, “In the interview I told them I heard the song come from one of the girls’ phones about a patient and I knew they had used it to take pictures of other employees. I can’t remember exactly, but I remember a name from the song, it was Patient #4 and had something to do with peanut butter phlegm. I don’t know what they were trying to be.” PCT F said she was familiar with Patient #4 and described her as kind, said “I loved her” and that she needed a bit more assistance than others. She needed one to two employees to help her get around and sat in her recliner and was elderly; she’d been a patient at the hospital a few times. During an interview on 10/14/2025 at 8:45am, RN E explained that RN B took a picture of him providing care to Patient #4. RN E described the photo as showing him standing over Patient #4 and placing a blanket on her, the photo was taken from behind and then shown to RN E by RN B. RN E explained that he worked on the unit with RN B from October 2024 to around January-February 2025 and while he was not aware of the exact date, it was during that time the photo was taken and shown to him and that he told RN B to delete it. RN E said “they teased me about being her boyfriend and I got along with her well so they would move me and change my patient load, so I had her. I told them during my interview I swapped from their shift to the other shift just to get away from them to be honest and one night they were talking about making a song and adding Patient #4 to it and they were singing it, talking about how it would go. I never saw it, and I said they shouldn’t do that. The staff members were RN A, RN B, RN C, and PCT D was probably there because she was the unit coordinator at the time. There wasn’t anything about photos at the time. It’s out in the media now and there were other behaviors, staff to staff, but not staff to patient that I’m aware of.” RN E continued to describe the staff behavior by saying, “I feel like everybody had heard rumors and knew what was going on but the main three were RN A, RN B, and RN C and I know that RN B and RN C took pictures of me and Patient #4. I don’t have any proof of what I’ve seen.” In response to whether this behavior violated policies or patient rights, RN E remarked, “Yeah, that’s common sense. That includes HIPAA (Health Information Portability and Accountability Act, a federal law that establishes standards to protect sensitive health information from disclosure without patient consent according to www.hhs.gov) policies, not having your cell phone out at work is probably a policy as well; common sense, HIPAA, patient rights, just being a good person.” On 10/14/2025 at 11:00am, an interview with registered nurse (RN) L took place in which she described that a staff member came to her to report an incident of a patient being photographed. The staff member explained to RN L there “had been a Snapchat thread going between several people and some patients. They had taken a picture of a patient and used AI to manipulate it and put little sayings on it. They took AI and made a song with patients’ first and last names on it. And, when a patient was on ‘Careview’ (the remote patient monitoring system) that the PCT at the desk watches on the screen, a picture was taken of them and said the patient was partially unclothed. The staff member had a picture of the AI and showed me, and I knew the patient.” RN L said she had the staff member provide a list of names of everyone who was involved and who had seen it on someone else’s device. RN L was able to confirm the name of the patient in the picture was Patient #1 and described that when Patient #1 is a patient in the hospital, “she doesn’t wear a gown, she wears her own clothes. You could tell the picture was taken through a window of Patient #1 outside going through her car and she had on sweatpants, lavender, and some type of t-shirt. I couldn’t tell if she was a patient at the time the picture was taken, but I knew she was on hospital grounds because her car was parked in the parking lot next to the ER. The picture they took of her at the car was the back of her, but somehow, they had manipulated another picture that showed her face with sunglasses on and some type of meme. It was two different poses but one picture, it showed her from afar from the back side and then her face from the chest up with sunglasses on.” RN L continued with the description of the employee behavior that was reported to her as one of the jingles made up included a reference to Patient #3 and “they were talking about his ‘rotten balls.’ Whenever Patient #3 was admitted to the hospital, he is always CHF (congestive heart failure); he always has edema (swelling) and one time when he was there, he had a lot of scrotum edema.” RN L explained that Staff K and Staff M told her they were gathering information and there was an active investigation and asked her not to discuss it. She recalled that sometime in September (2025) when she learned staff involved had been placed on administrative leave and that they might need her to work extra. She described this as possibly around five weeks after she became aware of the allegations and that a total of five people were placed on administrative leave. During an interview on 10/13/2025 at 4:26pm, the RM director explained the (facility’s) attorneys have advised that Staff M (the facility’s compliance officer who investigated the allegations) and Staff K (the facility human resource representative who investigated the allegations) were advised not to speak to the surveyor. In a follow up interview with the RM director on 10/14/2025 at 12:04pm, the RM director explained she spoke with Staff M and he said he was not aware of Patient #4 and that when staff talked about Patient #4 in interviews he conducted, he thought they were talking about Patient #1. A record review for Patient #4 confirmed the last inpatient admission for Patient #4 occurred on January 19, 2025. The orders for the admission on January 19, 2025, did not include orders for remote patient monitoring. Patient #4 was discharged to a skilled nursing facility on January 25, 2025. The record confirmed that RN B, RN C, RN E, and RN I were staff involved with Patient #4’s care during the admission from January 19-25, 2025. Patient #4’s record showed admissions to the facility on 12/16/2024 for inpatient acute care, an admission on 11/26/2024 for a swing-bed (skilled nursing services) admission, and an admission on 11/18/2024 for inpatient acute care. Reviews of the orders for each of these admissions revealed that only the swing-bed admission on 11/26/2024 included an order for “safety sitter” initiated on 12/01/2024 and discontinued on 12/12/2024 which documented “criteria fall risk. Sitter type: virtual.” The virtual order indicated remote patient monitoring was used. Patient #4 was discharged on 12/12/2024 with discharge diagnoses documented which included decreased activities of daily living, diabetes, dependence on oxygen, COPD (chronic obstructive pulmonary disease), dysphagia, decreased IADLs (instrumental activities of daily living, this includes tasks such as cooking and managing finances), obesity related hyperventilation syndrome, chronic panniculitis with candidiasis. On 12/16/2024, Patient #4 was readmitted to the facility for inpatient acute care with an admitting diagnosis of CHF (congestive heart failure) and pneumonia and was discharged on 12/19/2024 with a discharge diagnosis of CHF. An interview with the RM director on 10/14/2025 at 12:30pm during the review of Patient #4’s medical record included pointing out that since Patient #4 was last admitted to the facility in January, the evidence of the activity involving violation of patients’ rights may have begun earlier than the February time frame reported by the facility. Based on the descriptions of the photo depicting Patient #4 being taken from the screen where staff observe patients who have remote patient monitoring ordered, the record review suggests the timeframe when this photo could have been taken was between 12/1/2024 and 12/12/2024. The record review confirmed that RN B was involved with Patient #4’s admission which began on 11/26/2024 and included the use of the remote monitoring system. A record review for Patient #1 included only one inpatient admission which began on 2/10/2025 and was a swing-bed admission. The record described Patient #1 as having a below the knee amputation of the right lower extremity and in need of post op (after surgery) pain management, wound management, physical therapy, occupational therapy, speech therapy to evaluate for aspiration risk and strength her weak legs, as well as monitoring her multiple medical problems including very brittle diabetes mellitus type 1, dysautonomia, chronic back pain, hypothyroidism; history of multiple surgeries, including pancreatic transplant x2. Patient #1 was discharged to skilled nursing on 2/22/2025. Nurses involved in the care of Patient #1 during this admission included RN A, RN B, RN E, and RN L. A review of Patient #3’s record included an acute inpatient admission on 11/08/2024, a swing bed admission on 12/27/2024, a swing-bed admission on 2/3/2025, a swing bed admission on 3/26/2025, and a swing bed admission on 5/19/2025. The admission on 12/27/2024 documented an admission diagnosis for endocarditis with a discharge on 1/24/2024 to another hospital which documented “Patient to be discharged from skilled care and taken to the ER (emergency department) for evaluation of worsening CHF manifestation, worsening diabetic foot ulcer, and severe scrotal edema.” There were no orders for a sitter during this admission. Staff involved in the care of the patient during this admission included: RN H, RN I, RN J, PCT G, RN L, RN C, and PCT F. The admission on 2/3/2025 had an admitting diagnosis of wound of foot. The history of present illness (HPI) for the 2/3/2025 admission noted “patient admitted to (another facility) on 1/25/2025 with a chief complaint of CHF exacerbation manifested by extreme scrotal edema and evaluation of nonhealing right foot wound. The ultrasound showed marked scrotal wall thickening. ...He is transferred back to (subject facility) for SNF (skilled nursing facility) care, mostly in the form of wound care right foot. He has been in the hospital for the past 6 weeks.” Patient #3 was discharged on 2/28/2025 to home health. There was no remote patient monitoring ordered during the admission. The nurses involved in Patient #3’s care during the 2/3/2025 swing-bed admission included RN A, RN B, RN C, RN I, and RN E. The admission on 3/26/2025 described the admitting diagnosis as history of hypoglycemia and a discharge date of 4/4/2025 to home health services. The discharge diagnoses included chronic systolic CHF, weakness, chronic kidney disease, diabetic wounds bilateral (both) feet. There were no sitter orders during this visit. The admission note documented “Patient with a multitude chronic health problems, most troublesome is chronic ischemic systolic CHF, also type 2 diabetes mellitus on insulin, stage 3 chronic renal failure, chronic bilateral feet wounds and chronic neck and low back pain. Has basically been in the hospital since 11/2024.” Staff involved with this admission included RN H, PCT F, RN L, RN J, and PCT G. Another Swing bed admission on 5/19/2025 included admitting diagnoses of CHF Exacerbation, pelvic fracture, physical therapy/occupational therapy (PT/OT). Patient #3 was discharged on 5/28/2025 to home health services with discharge diagnoses of Right Pelvic Fracture, chronic systolic CHF, Chronic diabetic wounds of feet. There were no sitter services ordered during this admission. Staff involved in this admission included: RN H, RN E, PCT G, RN J, PCT F. A record review for Patient #2 included an acute care inpatient admission on 2/6/2025, a swing-bed admission on 5/13/2025, a swing-bed admission on 6/23/2025, and a swing-bed admission on 7/16/2025. The admission on 2/6/2025 described an admitting diagnosis of cellulitis great toe left foot and diabetic foot wound with pain to the great left toe for two weeks with drainage around the toenail. There was no remote monitoring ordered during this admission and Patient #2 was discharged to another hospital on 2/12/2025. Nurses involved in this admission included RN A, RN L, RN B, and RN I. Patient #2 had a swing-bed admission on 7/16/2025 with an admitting diagnosis of gangrene following a Chopart amputation to the right foot (a type of amputation that removes part of the foot). Patient #2 was discharged to another hospital on 8/7/2025. Nurses involved in this admission included RN I, RN E, RN B, RN L, and RN C. Patient #2 had a swing bed admission on 6/23/2025 with an admission diagnosis of right trans metatarsal (foot) amputation. Patient #2 was discharged on 7/8/2025 to another hospital with a discharge diagnosis of gangrene on the right foot and severe peripheral artery disease. No sitter services were ordered during this admission. The admission note documented “patient in need of wound care, pain management, and continued antibiotics. She has known peripheral arterial disease with a history of systolic congestive heart failure with ejection fraction of 36%, peripheral arterial disease with a previous admission for nonhealing left great toe wound requiring amputation 4/23/2025 and later requiring an above the knee amputation on 5/02/2025, due to severe stenosis with no options for revascularization at that time. Patient subsequently developed gangrene involving her right great toe, and right 4th toe, and extending over to other parts of her foot resulting in the aforementioned transmetatarsal amputation 6/15/2025.” Staff involved in this admission included: RN B, PCT G, RN C, RN A, PCY F, and RN J. Patient #2 had an admission on 5/13/2025 with an admitting diagnosis of “above the knee amputation of left lower extremity.” She was discharged on 6/13/2025 with a discharge diagnosis of “Gangrenous toe.” There were no sitter orders during this admission. The admission note described “after reaching maximum acute care hospital benefit at (another) hospital 4/25/2025 through 5/13/2025 with patient having severe peripheral arterial disease, status post angioplasty (a procedure to open locked or narrowed arteries), and stent to the left superior femoral (upper leg/thigh) artery and popliteal (knee) arteries, with patient undergoing above-the-knee amputation on the left lower extremity, and is now battling gangrenous changes involving the right lower extremity.” Staff involved in this admission included: RN E, RN H, RN C, PCT F, RN A, RN B, PCT G, and RN L. A review of the facility’s Code of Conduct included a description on page 10 concerning the value of protecting private information and documented “We protect private and confidential information. Those whom we serve trust that we will protect the information provided to us including their health information and personal information.” The Code of Conduct included direction to staff that “Posting protected health information or photographs on a web site, social media page or public forum is strictly prohibited, even if the patient/client is not identified. We do not use our personal devices to text or transmit protected health information for any reason unless otherwise allowed by (facility) policy. We do not take or transmit photographs of those to whom we provide services except as required within our policies.” During an interview on 10/24/2025 at 12:00pm, Patient #3 described the experience at the hospital as “when I’m there I’m in pretty bad shape, sedated and medicated.” He explained that he was invited to a meeting at the hospital and was informed photographs were taken of him in the middle of the night when he was asleep. Patient #3 said, “that’s when I knew my rights were violated. All they would tell me was that the photographs were really bad, they were awful, but they didn’t show me and said they didn’t have them.” Patient #3 described the impact this had on his life when he said “this is a very small town, small community and everybody knows everybody. I feel embarrassed. It enrages me and I feel, and my family feels, that you could go to the hospital in your worst times and put your life in their hands and want them to take care of you and that was not the case. These nurses who did these things, these perversions of their duties; it just shouldn’t happen that way. I’m enraged, embarrassed, I don’t know where these pictures are. It’s kind of disappointing to me that the hospital up here, that the management of the hospital tried to sweep this under the rug and insulted my intelligence. I felt like they tried to buy me off and no amount of money will allow you to buy your dignity back. I gave them several chances; we went back and forth. I met with them at the hospital and talked to them on the phone, they just tried to throw a monetary value to be done with it.” An interview with Patient #2 took place on 10/24/2025 at 12:30pm. Patient #2 described that she had a meeting with people from the hospital and “they said that pictures were taken but I don’t know if they were. I felt bad because they could take those pictures and do anything and post things with me with no clothes on and change it and do whatever they want.” Patient #2 described that she felt her rights were violated as she remembered “two women coming in my room and stood at the foot of my bed and kept watching me and talking and I was under my medication. So really, they violated my privacy. I do not remember their names, and I can’t remember too much how they looked, but I remember they were two women.” When asked how this has impacted her life, Patient #2 said, “I ain’t been good since I left there. I take medication and I take medication for depression. I used to take it once a day and now I take it twice a day.” She added, “they came to the facility and offered my $25,000. I told them I didn’t want that, that’s hush money, and they violated my privacy.” The description of a critical access hospital accessed from cms.gov on 10/28/2025 at 11:24am described the facility as on which must “be located in a rural area or an area that is treated as rural.” A television broadcast dated 10/07/2025 and accessed on 10/28/2025 at https://www.wkrg.com/northwest-florida/santa-rosa-county/jay-hospital-faces-lawsuits-after-employees-allegedly-took-photos-of-patients-and-shared-them-online/ described that the facility fired employees over recent allegations of inappropriate patient pictures being released via social media. An attorney interviewed for the news piece described that “victims” contacted him “after hospital personnel told victims about the incidents” and “gave victims the chance to sign a non-disclosure form in exchange for money.” The attorney was quoted describing one of the “victims’” report as “she says she woke up without her clothes on after being medicated; one of the staff nurses ...made a crude comment about how all night she was showing her body parts basically, and that they all were able to see them in the hall.” An interview with Patient #2 took place on 10/24/2025 at 12:30pm. Patient #2 described that she had a meeting with people from the hospital and “they said that pictures were taken but I don’t know if they were. I felt bad because they could take those pictures and do anything and post things with me with no clothes on and change it and do whatever they want.” When asked how this has impacted her life, Patient #2 said, “I ain’t been good since I left there. I take medication and I take medication for depression. I used to take it once a day and now I take it twice a day. They ain’t nothing changed, but I already lost of my legs and now I lost the other, so I live with my daughter.” She added, “they came to the facility and offered my $25,000. I told them I didn’t want that, that’s hush money, and they violated my privacy.” Review of a pamphlet titled “A Nurse’s Guide to the Use of Social Media,” published by the National Council on State Boards of Nursing and accessed at https://floridasnursing.gov/forms/nurse-guide-social-media-info.pdf on 10/25/2025 at 10:31am, provided a standard for nurses regarding the use of social media outside of the work setting and using personal electronic devices such as cell phones related to patient interactions. The pamphlet explained “Privacy relates to the patient’s expectation and right to be treated with dignity and respect. Effective nurse/patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Patients will be hesitant to disclose personal information if they fear it will be disseminated beyond those who have a legitimate ‘need to know.’ Any breach of this trust, even inadvertent, damages the nurse/patient relationship and the general trustworthiness of the profession of nursing.” The pamphlet described “Examples may include comments in which patients are described with enough sufficient detail to be identified, referring to patients in a degrading or demeaning manner, or posting videos or photos of patients.” The facility provided information confirming the title, hire date and training completions for RN I, RN B, RN C, RN A, PCT D, and RN E which confirmed that all staff members received training on basic healthcare information, the facility Code of Conduct, HIPAA, and mandatory incident reporting within the past calendar year of the date of the survey. The hire dates for the staff are as follows: RN A - 2/24/2020 RN B - 6/1/2021 RN C - 3/20/2023 PCT D - 10/02/2017 RN E - 8/21/2023 RN I - 7/31/2024 A policy titled “Abuse, Sexual Abuse and Sexual Misconduct Allegations against Workforce Members” with an effective date of October 2024 defined abuse as “any willful act or threatened act by a Workforce Member that causes or is likely to cause significant impairment to a patient’s physical, mental, or emotional health. Abuse includes acts and omissions.” The Procedure section of the policy listed expected actions as: Workforce members who are aware of or who suspect that another Workforce Member has committed Abuse, Sexual Abuse or Sexual Misconduct, will: a. Promptly report the suspicion to their immediate supervisor, who will report the incident to the Risk Manager On-Call. For hospital-based incidents, the supervisor may alert the House Supervisor who will report the incident to the Risk Manager On-Call. B. Enter the facts supporting the allegation into (the facility’s) Event Reporting System. Initial action by Risk Management. Upon receipt of a report of Abuse, Sexual Abuse, or Sexual Misconduct by a Workforce Member, the Risk Manager will: d. Notify Human Resources if a Team Member is being accused. Human Resources will work with the appropriate leaders to place the Team Member on suspension, if appropriate pending investigation. Preliminary Investigation when the allegation involves a Team Member: a. The assigned Risk Manager and Human Resources will immediately complete a Preliminary Investigation of the allegation. Unless the allegation can be ruled out conclusively, the investigation will continue as set forth in Section 5 below. B. Based upon the outcome of the Preliminary Investigation, Human Resources will determine whether the involved Team Member may return to work. Regardless of the outcome of the Preliminary Investigation, if the accused Team Member is permitted to return to work, he or she will not be assigned to the patient involved in the allegation. A policy titled “Comprehensive Filming” with an effective date of November 2024 was reviewed and included a statement of purpose as “to provide standards on how to identify when recordings, films or other images of patients and Workforce Members are allowed, and to establish procedures to protect patient and workforce safety and privacy during the same.” The policy was stated as “consistent with its respect for patient and Workforce Member privacy and confidentiality, (the facility) will obtain appropriate permission and consent to Film patients, visitors, and Workforce Members ...v. Filming of any patient care treatment or procedure is prohibited, except as otherwise allowed below.” The policy described the specific exceptions which would allow filming within the facility and the consents required in order to allow filming. The policy included a statement that “all filming where patient or Workforce Member consent is required, the following apply: a. Individuals being filmed must be informed of the nature and proposed purpose of the filming and of its intended use.””

“PRIVACY AND SAFETY CFR(s): The patient has the right to personal privacy. This Standard is not met as evidenced by: 39374 Based on interviews, record reviews and review of facility documents, the facility failed to protect personal health information of 3 of 4 patients sampled (#2, #3, and #4) who were photographed by hospital staff members and/or entered patient information, including first and last names and medical conditions into an artificial intelligence (AI) app which generates songs. The evidence indicated the duration of the failure to protect patients’ right to be free from abuse and harassment began as early as December, 2024 and continued through approximately September, 2025. The findings include: On 10/13/2025 at 3:30pm, a telephone interview with registered nurse (RN) I took place related to staff taking and showing photos of patients. RN I said at sometime in July 2025, another registered nurse working at the facility, RN B, used her personal cell phone to display photos of Patient #4. During the conversation with her coworkers, RN I was told that Patient #4 had passed away, and RN I guessed the photo was taken during Patient #4’s last admission to the facility. RN I described that, while showing a picture of Patient #4, RN B was joking about Patient #4’s body and how “she kept spitting everywhere.” RN I explained the conversation with RN B took place at work in the charting room and another registered nurse, RN C, showed a photo on her cell phone of Patient #2, a female patient with an above the knee amputation. The photo showed Patient #2 sitting up at the edge of the bed and looked like it was taken from close up. RN I described that Patient #2’s body was covered in the photo except for her right foot and her face. RN C and RN B were making jokes about Patient #2 and described the picture as trying to help her because she was straddling the trash can to urinate. RN I described that the photo of Patient #2 was not a picture from the remote monitoring system screen and that it was not clear if the photo was on a Snapchat app or taken with the camera on the phone. RN I confirmed there were a “few other nurses” present who saw the photos and this was a violation of patient privacy and that the policy instructs staff are “not even to take selfies because patient privacy and information can be leaked and they go over these things in our policy.” RN I continued by saying “I don’t know if you’re aware of the songs that were made using an AI (artificial intelligence) generated app that RN C and RN B were using with their names, certain medical conditions, and other things of that nature. I don’t know if it was posted or shared, but they were on their personal devices. This was around the time that I saw the photos. Patient #4 was one, and it contained her name and was about the fact that she spits up a lot of the time and the song was called ‘peanut butter phlegm’ because that’s what she coughed up. There were others, one about Patient #2, it said, ‘her leg is rotten’ and it’s about her diabetes and talked about her medical condition with her legs. There was one mentioning Patient #3. He had an enlarged scrotum, so it referred to ‘his big balls.’ These songs were played in the charting room, RN C and RN B both had them on their phones. RN C showed them to me on her app and RN B talked about them being on her phone, too. Not sure what the app is but it is an AI generated app. I don’t know if its like an Instagram where you can post, I’m not sure.” On 10/14/2025 at 8:15am, a telephone interview took place with patient care technician (PCT) F who denied seeing any photos of patients. PCT F confirmed being aware that RN A, RN B, RN C, and PCT D were terminated from their positions related to allegedly taking or sharing photos of patients. PCT F described being interviewed during the facility investigation of the incident and said, “In the interview I told them I heard the song come from one of the girls’ phones about a patient and I knew they had used it to take pictures of other employees. I can’t remember exactly, but I remember a name from the song, it was Patient #4 and had something to do with peanut butter phlegm. I don’t know what they were trying to be.” PCT F said she was familiar with Patient #4 and described her as kind, said “I loved her” and that she needed a bit more assistance than others. She needed one to two employees to help her get around and sat in her recliner and was elderly; she’d been a patient at the hospital a few times. During an interview on 10/14/2025 at 8:45am, RN E explained that RN B took a picture of him providing care to Patient #4. RN E described the photo as showing him standing over Patient #4 and placing a blanket on her, the photo was taken from behind and then shown to RN E by RN B. RN E explained that he worked on the unit with RN B from October 2024 to around January-February 2025 and while he was not aware of the exact date, it was during that time the photo was taken and shown to him and that he told RN B to delete it. RN E said “they teased me about being her boyfriend and I got along with her well so they would move me and change my patient load, so I had her. I told them during my interview I swapped from their shift to the other shift just to get away from them to be honest and one night they were talking about making a song and adding Patient #4 to it and they were singing it, talking about how it would go. I never saw it, and I said they shouldn’t do that. The staff members were RN A, RN B, RN C, and PCT D was probably there because she was the unit coordinator at the time. There wasn’t anything about photos at the time. It’s out in the media now and there were other behaviors, staff to staff, but not staff to patient that I’m aware of.” RN E continued to describe the staff behavior by saying, “I feel like everybody had heard rumors and knew what was going on but the main three were RN A, RN B, and RN C and I know that RN B and RN C took pictures of me and Patient #4. I don’t have any proof of what I’ve seen.” In response to whether this behavior violated policies or patient rights, RN E remarked, “Yeah, that’s common sense. That includes HIPAA (Health Information Portability and Accountability Act, a federal law that establishes standards to protect sensitive health information from disclosure without patient consent according to www.hhs.gov) policies, not having your cell phone out at work is probably a policy as well; common sense, HIPAA, patient rights, just being a good person.” On 10/14/2025 at 11:00am, an interview with registered nurse (RN) L took place in which she described that a staff member came to her to report an incident of a patient being photographed. The staff member explained to RN L there “had been a Snapchat thread going between several people and some patients. They had taken a picture of a patient and used AI to manipulate it and put little sayings on it. They took AI and made a song with patients’ first and last names on it. RN L continued with the description of the employee behavior that was reported to her as one of the jingles made up included a reference to Patient #3 and “they were talking about his ‘rotten balls.’ Whenever Patient #3 was admitted to the hospital, he is always CHF (congestive heart failure); he always has edema (swelling) and one time when he was there, he had a lot of scrotum edema.” RN L explained that Staff K and Staff M told her they were gathering information and there was an active investigation and asked her not to discuss it. She recalled that sometime in September (2025) when she learned staff involved had been placed on administrative leave and that they might need her to work extra. She described this as possibly around five weeks after she became aware of the allegations and that a total of five people were placed on administrative leave. During an interview on 10/13/2025 at 4:26pm, the RM director explained the (facility’s) attorneys have advised that Staff M (the facility’s compliance officer who investigated the allegations) and Staff K (the facility human resource representative who investigated the allegations) were advised not to speak to the surveyor. In a follow up interview with the RM director on 10/14/2025 at 12:04pm, the RM director explained she spoke with Staff M and he said he was not aware of Patient #4 and that when staff talked about Patient #4 in interviews he conducted, he thought they were talking about Patient #1. A record review for Patient #4 confirmed the last inpatient admission for Patient #4 occurred on January 19, 2025. The orders for the admission on January 19, 2025, did not include orders for remote patient monitoring. Patient #4 was discharged to a skilled nursing facility on January 25, 2025. The record confirmed that RN B, RN C, RN E, and RN I were staff involved with Patient #4’s care during the admission from January 19-25, 2025. Patient #4’s record showed admissions to the facility on 12/16/2024 for inpatient acute care, an admission on 11/26/2024 for a swing-bed (skilled nursing services) admission, and an admission on 11/18/2024 for inpatient acute care. Reviews of the orders for each of these admissions revealed that only the swing-bed admission on 11/26/2024 included an order for “safety sitter” initiated on 12/01/2024 and discontinued on 12/12/2024 which documented “criteria fall risk. Sitter type: virtual.” The virtual order indicated remote patient monitoring was used. Patient #4 was discharged on 12/12/2024 with discharge diagnoses documented which included decreased activities of daily living, diabetes, dependence on oxygen, COPD (chronic obstructive pulmonary disease), dysphagia, decreased IADLs (instrumental activities of daily living, this includes tasks such as cooking and managing finances), obesity related hyperventilation syndrome, chronic panniculitis with candidiasis. A review of Patient #3’s record included an acute inpatient admission on 11/08/2024 with admitting diagnosis: heart failure with reduced ejection fraction. Patient #3 was discharged on 11/12/2024 with a diagnosis of systolic-ischemic CHF. No sitter services were ordered. An admission note documented Patient #3 was having some increased edema of lower extremities and shortness of breath. Staff involved in care during this admission included: RN H, RN B, RN C, PCT G, PCT F, and RN J. A review of Patient #3’s record included an acute inpatient admission on 11/08/2024 with admitting diagnosis: heart failure with reduced ejection fraction. Patient #3 was discharged on 11/12/2024 with a diagnosis of systolic-ischemic CHF. No sitter services were ordered. An admission note documented Patient #3 was having some increased edema of lower extremities and shortness of breath. Staff involved in care during this admission included: RN H, RN B, RN C, PCT G, PCT F, and RN J. A record review for Patient #2 included an acute care inpatient admission on 2/6/2025. The admission on 2/6/2025 described an admitting diagnosis of cellulitis great toe left foot and diabetic foot wound with pain to the great left toe for two weeks with drainage around the toenail. There was no remote monitoring ordered during this admission and Patient #2 was discharged to another hospital on 2/12/2025. Nurses involved in this admission included RN A, RN L, RN B, and RN I. A review of the facility’s Code of Conduct included a description on page 10 concerning the value of protecting private information and documented “We protect private and confidential information. Those whom we serve trust that we will protect the information provided to us including their health information and personal information.” The Code of Conduct included direction to staff that “Posting protected health information or photographs on a web site, social media page or public forum is strictly prohibited, even if the patient/client is not identified. We do not use our personal devices to text or transmit protected health information for any reason unless otherwise allowed by (facility) policy. We do not take or transmit photographs of those to whom we provide services except as required within our policies.” During an interview on 10/24/2025 at 12:00pm, Patient #3 described the experience at the hospital as “when I’m there I’m in pretty bad shape, sedated and medicated.” He explained that he was invited to a meeting at the hospital and was informed photographs were taken of him in the middle of the night when he was asleep. Patient #2 said, “that’s when I knew my rights were violated. All they would tell me was that the photographs were really bad, they were awful, but they didn’t show me and said they didn’t have them.” Patient #2 described the impact this had on his life when he said “this is a very small town, small community and everybody knows everybody. I feel embarrassed. It enrages me and I feel, and my family feels, that you could go to the hospital in your worst times and put your life in their hands and want them to take care of you and that was not the case. These nurses who did these things, these perversions of their duties; it just shouldn’t happen that way. I’m enraged, embarrassed, I don’t know where these pictures are. It’s kind of disappointing to me that the hospital up here, that the management of the hospital tried to sweep this under the rug and insulted my intelligence. I felt like they tried to buy me off and no amount of money will allow you to buy your dignity back. I gave them several chances; we went back and forth. I met with them at the hospital and talked to them on the phone, they just tried to throw a monetary value to be done with it.” An interview with Patient #2 took place on 10/24/2025 at 12:30pm. Patient #2 described that she had a meeting with people from the hospital and “they said that pictures were taken but I don’t know if they were. I felt bad because they could take those pictures and do anything and post things with me with no clothes on and change it and do whatever they want.” Patient #2 described that she felt her rights were violated as she remembered “two women coming in my room and stood at the foot of my bed and kept watching me and talking and I was under my medication. So really, they violated my privacy. I do not remember their names, and I can’t remember too much how they looked, but I remember they were two women.” When asked how this has impacted her life, Patient #2 said, “I ain’t been good since I left there. I take medication and I take medication for depression. I used to take it once a day and now I take it twice a day.” She added, “they came to the facility and offered my $25,000. I told them I didn’t want that, that’s hush money, and they violated my privacy.” The facility provided information confirming the title, hire date and training completions for RN I, RN B, RN C, RN A, PCT D, and RN E which confirmed that all staff members received training on basic healthcare information, the facility Code of Conduct, HIPAA, and mandatory incident reporting within the past calendar year of the date of the survey. The hire dates for the staff are as follows: RN A - 2/24/2020;RN B - 6/1/2021;RN C - 3/20/2023;PCT D - 10/02/2017;RN E - 8/21/2023; and RN I - 7/31/2024. A policy titled “Comprehensive Filming” with an effective date of November 2024 was reviewed and included a statement of purpose as “to provide standards on how to identify when recordings, films or other images of patients and Workforce Members are allowed, and to establish procedures to protect patient and workforce safety and privacy during the same.” The policy was stated as “consistent with its respect for patient and Workforce Member privacy and confidentiality, (the facility) will obtain appropriate permission and consent to Film patients, visitors, and Workforce Members ...v. Filming of any patient care treatment or procedure is prohibited, except as otherwise allowed below.” The policy described the specific exceptions which would allow filming within the facility and the consents required in order to allow filming. The policy included a statement that “all filming where patient or Workforce Member consent is required, the following apply: a. Individuals being filmed must be informed of the nature and proposed purpose of the filming and of its intended use.” Review of a pamphlet titled “A Nurse’s Guide to the Use of Social Media,” published by the National Council on State Boards of Nursing and accessed at https://floridasnursing.gov/forms/nurse-guide-social-media-info.pdf on 10/25/2025 at 10:31am, provided a standard for nurses regarding the use of social media outside of the work setting and using personal electronic devices such as cell phones related to patient interactions. The pamphlet explained “Privacy relates to the patient’s expectation and right to be treated with dignity and respect. Effective nurse/patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Patients will be hesitant to disclose personal information if they fear it will be disseminated beyond those who have a legitimate ‘need to know.’ Any breach of this trust, even inadvertent, damages the nurse/patient relationship and the general trustworthiness of the profession of nursing.” The pamphlet described “Examples may include comments in which patients are described with enough sufficient detail to be identified, referring to patients in a degrading or demeaning manner, or posting videos or photos of patients.””

“PRIVACY AND SAFETY CFR(s): The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 39374 Based on interviews, record reviews and review of facility documents, the facility failed to prevent abuse or harassment of 3 of 4 patients sampled (#2, #3, and #4) who were photographed by hospital staff members and/or entered patient information, including first and last names and medical conditions into an artificial intelligence (AI) app which generates songs. The evidence indicated the duration of the failure to protect patients’ right to be free from abuse and harassment began as early as December, 2024 and continued through approximately September, 2025. The findings include: On 10/13/2025 at 3:30pm, a telephone interview with registered nurse (RN) I took place related to staff taking and showing photos of patients. RN I said at sometime in July 2025, another registered nurse working at the facility, RN B, used her personal cell phone to display photos of Patient #4. During the conversation with her coworkers, RN I was told that Patient #4 had passed away, and RN I guessed the photo was taken during Patient #4’s last admission to the facility. RN I described that, while showing a picture of Patient #4, RN B was joking about Patient #4’s body and how “she kept spitting everywhere.” RN I explained the conversation with RN B took place at work in the charting room and another registered nurse, RN C, showed a photo on her cell phone of Patient #2, a female patient with an above the knee amputation. The photo showed Patient #2 sitting up at the edge of the bed and looked like it was taken from close up. RN I described that Patient #2’s body was covered in the photo except for her right foot and her face. RN C and RN B were making jokes about Patient #2 and described the picture as trying to help her because she was straddling the trash can to urinate. RN I described that the photo of Patient #2 was not a picture from the remote monitoring system screen and that it was not clear if the photo was on a Snapchat app or taken with the camera on the phone. RN I confirmed there were a “few other nurses” present who saw the photos and this was a violation of patient privacy and that the policy instructs staff are “not even to take selfies because patient privacy and information can be leaked and they go over these things in our policy.” RN I continued by saying “I don’t know if you’re aware of the songs that were made using an AI (artificial intelligence) generated app that RN C and RN B were using with their names, certain medical conditions, and other things of that nature. I don’t know if it was posted or shared, but they were on their personal devices. This was around the time that I saw the photos. Patient #4 was one, and it contained her name and was about the fact that she spits up a lot of the time and the song was called ‘peanut butter phlegm’ because that’s what she coughed up. There were others, one about Patient #2, it said, ‘her leg is rotten’ and it’s about her diabetes and talked about her medical condition with her legs. There was one mentioning Patient #3. He had an enlarged scrotum, so it referred to ‘his big balls.’ These songs were played in the charting room, RN C and RN B both had them on their phones. RN C showed them to me on her app and RN B talked about them being on her phone, too. Not sure what the app is but it is an AI generated app. I don’t know if its like an Instagram where you can post, I’m not sure.” On 10/14/2025 at 8:15am, a telephone interview took place with patient care technician (PCT) F who denied seeing any photos of patients. PCT F confirmed being aware that RN A, RN B, RN C, and PCT D were terminated from their positions related to allegedly taking or sharing photos of patients. PCT F described being interviewed during the facility investigation of the incident and said, “In the interview I told them I heard the song come from one of the girls’ phones about a patient and I knew they had used it to take pictures of other employees. I can’t remember exactly, but I remember a name from the song, it was Patient #4 and had something to do with peanut butter phlegm. I don’t know what they were trying to be.” PCT F said she was familiar with Patient #4 and described her as kind, said “I loved her” and that she needed a bit more assistance than others. She needed one to two employees to help her get around and sat in her recliner and was elderly; she’d been a patient at the hospital a few times. During an interview on 10/14/2025 at 8:45am, RN E explained that RN B took a picture of him providing care to Patient #4. RN E described the photo as showing him standing over Patient #4 and placing a blanket on her, the photo was taken from behind and then shown to RN E by RN B. RN E explained that he worked on the unit with RN B from October 2024 to around January-February 2025 and while he was not aware of the exact date, it was during that time the photo was taken and shown to him and that he told RN B to delete it. RN E said “they teased me about being her boyfriend and I got along with her well so they would move me and change my patient load, so I had her. I told them during my interview I swapped from their shift to the other shift just to get away from them to be honest and one night they were talking about making a song and adding Patient #4 to it and they were singing it, talking about how it would go. I never saw it, and I said they shouldn’t do that. The staff members were RN A, RN B, RN C, and PCT D was probably there because she was the unit coordinator at the time. There wasn’t anything about photos at the time. It’s out in the media now and there were other behaviors, staff to staff, but not staff to patient that I’m aware of.” RN E continued to describe the staff behavior by saying, “I feel like everybody had heard rumors and knew what was going on but the main three were RN A, RN B, and RN C and I know that RN B and RN C took pictures of me and Patient #4. I don’t have any proof of what I’ve seen.” In response to whether this behavior violated policies or patient rights, RN E remarked, “Yeah, that’s common sense. That includes HIPAA (Health Information Portability and Accountability Act, a federal law that establishes standards to protect sensitive health information from disclosure without patient consent according to www.hhs.gov) policies, not having your cell phone out at work is probably a policy as well; common sense, HIPAA, patient rights, just being a good person.” On 10/14/2025 at 11:00am, an interview with registered nurse (RN) L took place in which she described that a staff member came to her to report an incident of a patient being photographed. The staff member explained to RN L there “had been a Snapchat thread going between several people and some patients. They had taken a picture of a patient and used AI to manipulate it and put little sayings on it. They took AI and made a song with patients’ first and last names on it. RN L continued with the description of the employee behavior that was reported to her as one of the jingles made up included a reference to Patient #3 and “they were talking about his ‘rotten balls.’ Whenever Patient #3 was admitted to the hospital, he is always CHF (congestive heart failure); he always has edema (swelling) and one time when he was there, he had a lot of scrotum edema.” RN L explained that Staff K and Staff M told her they were gathering information and there was an active investigation and asked her not to discuss it. She recalled that sometime in September (2025) when she learned staff involved had been placed on administrative leave and that they might need her to work extra. She described this as possibly around five weeks after she became aware of the allegations and that a total of five people were placed on administrative leave. During an interview on 10/13/2025 at 4:26pm, the RM director explained the (facility’s) attorneys have advised that Staff M (the facility’s compliance officer who investigated the allegations) and Staff K (the facility human resource representative who investigated the allegations) were advised not to speak to the surveyor. In a follow up interview with the RM director on 10/14/2025 at 12:04pm, the RM director explained she spoke with Staff M and he said he was not aware of Patient #4 and that when staff talked about Patient #4 in interviews he conducted, he thought they were talking about Patient #1. During an interview on 10/24/2025 at 12:00pm, Patient #3 described the experience at the hospital as “when I’m there I’m in pretty bad shape, sedated and medicated.” He explained that he was invited to a meeting at the hospital and was informed photographs were taken of him in the middle of the night when he was asleep. Patient #2 said, “that’s when I knew my rights were violated. All they would tell me was that the photographs were really bad, they were awful, but they didn’t show me and said they didn’t have them.” Patient #2 described the impact this had on his life when he said “this is a very small town, small community and everybody knows everybody. I feel embarrassed. It enrages me and I feel, and my family feels, that you could go to the hospital in your worst times and put your life in their hands and want them to take care of you and that was not the case. These nurses who did these things, these perversions of their duties; it just shouldn’t happen that way. I’m enraged, embarrassed, I don’t know where these pictures are. It’s kind of disappointing to me that the hospital up here, that the management of the hospital tried to sweep this under the rug and insulted my intelligence. I felt like they tried to buy me off and no amount of money will allow you to buy your dignity back. I gave them several chances; we went back and forth. I met with them at the hospital and talked to them on the phone, they just tried to throw a monetary value to be done with it.” An interview with Patient #2 took place on 10/24/2025 at 12:30pm. Patient #2 described that she had a meeting with people from the hospital and “they said that pictures were taken but I don’t know if they were. I felt bad because they could take those pictures and do anything and post things with me with no clothes on and change it and do whatever they want.” When asked how this has impacted her life, Patient #2 said, “I ain’t been good since I left there. I take medication and I take medication for depression. I used to take it once a day and now I take it twice a day. They ain’t nothing changed, but I already lost of my legs and now I lost the other, so I live with my daughter.” She added, “they came to the facility and offered my $25,000. I told them I didn’t want that, that’s hush money, and they violated my privacy.” A record review for Patient #4 confirmed the last inpatient admission for Patient #4 occurred on January 19, 2025. The orders for the admission on January 19, 2025, did not include orders for remote patient monitoring. Patient #4 was discharged to a skilled nursing facility on January 25, 2025. The record confirmed that RN B, RN C, RN E, and RN I were staff involved with Patient #4’s care during the admission from January 19-25, 2025. On 12/16/2024, Patient #4 was readmitted to the facility for inpatient acute care with an admitting diagnosis of CHF (congestive heart failure) and pneumonia and was discharged on 12/19/2024 with a discharge diagnosis of CHF. A review of Patient #3’s record included an acute inpatient admission on 11/08/2024 with admitting diagnosis: heart failure with reduced ejection fraction. Patient #3 was discharged on 11/12/2024 with a diagnosis of systolic-ischemic CHF. No sitter services were ordered. An admission note documented Patient #3 was having some increased edema of lower extremities and shortness of breath. Staff involved in care during this admission included: RN H, RN B, RN C, PCT G, PCT F, and RN J. A record review for Patient #2 included an acute care inpatient admission on 2/6/2025. The admission on 2/6/2025 described an admitting diagnosis of cellulitis great toe left foot and diabetic foot wound with pain to the great left toe for two weeks with drainage around the toenail. There was no remote monitoring ordered during this admission and Patient #2 was discharged to another hospital on 2/12/2025. Nurses involved in this admission included RN A, RN L, RN B, and RN I. A review of the facility’s Code of Conduct included a description on page 10 concerning the value of protecting private information and documented “We protect private and confidential information. Those whom we serve trust that we will protect the information provided to us including their health information and personal information.” The Code of Conduct included direction to staff that “Posting protected health information or photographs on a web site, social media page or public forum is strictly prohibited, even if the patient/client is not identified. We do not use our personal devices to text or transmit protected health information for any reason unless otherwise allowed by (facility) policy. We do not take or transmit photographs of those to whom we provide services except as required within our policies.” The facility provided information confirming the title, hire date and training completions for RN I, RN B, RN C, RN A, PCT D, and RN E which confirmed that all staff members received training on basic healthcare information, the facility Code of Conduct, HIPAA, and mandatory incident reporting within the past calendar year of the date of the survey. The hire dates for the staff are as follows: RN A - 2/24/2020 RN B - 6/1/2021 RN C - 3/20/2023 PCT D - 10/02/2017 RN E - 8/21/2023 RN I - 7/31/2024 A policy titled “Abuse, Sexual Abuse and Sexual Misconduct Allegations against Workforce Members” with an effective date of October 2024 defined abuse as “any willful act or threatened act by a Workforce Member that causes or is likely to cause significant impairment to a patient’s physical, mental, or emotional health. Abuse includes acts and omissions.” The Procedure section of the policy listed expected actions as: Workforce members who are aware of or who suspect that another Workforce Member has committed Abuse, Sexual Abuse or Sexual Misconduct, will: a. Promptly report the suspicion to their immediate supervisor, who will report the incident to the Risk Manager On-Call. For hospital-based incidents, the supervisor may alert the House Supervisor who will report the incident to the Risk Manager On-Call. B. Enter the facts supporting the allegation into (the facility’s) Event Reporting System. Initial action by Risk Management. Upon receipt of a report of Abuse, Sexual Abuse, or Sexual Misconduct by a Workforce Member, the Risk Manager will: d. Notify Human Resources if a Team Member is being accused. Human Resources will work with the appropriate leaders to place the Team Member on suspension, if appropriate pending investigation. Preliminary Investigation when the allegation involves a Team Member: a. The assigned Risk Manager and Human Resources will immediately complete a Preliminary Investigation of the allegation. Unless the allegation can be ruled out conclusively, the investigation will continue as set forth in Section 5 below. B. Based upon the outcome of the Preliminary Investigation, Human Resources will determine whether the involved Team Member may return to work. Regardless of the outcome of the Preliminary Investigation, if the accused Team Member is permitted to return to work, he or she will not be assigned to the patient involved in the allegation. A policy titled “Comprehensive Filming” with an effective date of November 2024 was reviewed and included a statement of purpose as “to provide standards on how to identify when recordings, films or other images of patients and Workforce Members are allowed, and to establish procedures to protect patient and workforce safety and privacy during the same.” The policy was stated as “consistent with its respect for patient and Workforce Member privacy and confidentiality, (the facility) will obtain appropriate permission and consent to Film patients, visitors, and Workforce Members ...v. Filming of any patient care treatment or procedure is prohibited, except as otherwise allowed below.” The policy described the specific exceptions which would allow filming within the facility and the consents required in order to allow filming. The policy included a statement that “all filming where patient or Workforce Member consent is required, the following apply: a. Individuals being filmed must be informed of the nature and proposed purpose of the filming and of its intended use.” Review of a pamphlet titled “A Nurse’s Guide to the Use of Social Media,” published by the National Council on State Boards of Nursing and accessed at https://floridasnursing.gov/forms/nurse-guide-social-media-info.pdf on 10/25/2025 at 10:31am, provided a standard for nurses regarding the use of social media outside of the work setting and using personal electronic devices such as cell phones related to patient interactions. The pamphlet explained “Privacy relates to the patient’s expectation and right to be treated with dignity and respect. Effective nurse/patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Patients will be hesitant to disclose personal information if they fear it will be disseminated beyond those who have a legitimate ‘need to know.’ Any breach of this trust, even inadvertent, damages the nurse/patient relationship and the general trustworthiness of the profession of nursing.” The pamphlet described “Examples may include comments in which patients are described with enough sufficient detail to be identified, referring to patients in a degrading or demeaning manner, or posting videos or photos of patients.””