Middleburg Rehabilitation And Nursing Center

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #70 and #47) of nine residents observed during medication administration. RN B failed to perform hand hygiene as required while administering medications to more than one resident. The findings include:
1.During a medication administration observation on 01/14/2026 at 9:19 AM, Registered Nurse (RN) B began preparing medications for Resident #70. This included oral medications and eye drops. RN B wore gloves while preparing the medications and proceeded to Resident #70's room. The nurse entered Resident #70's room and did not perform hand hygiene. RN B placed the oral medications in the resident's palm at the resident's request and handed her a cup of water. Resident #70 swallowed her oral medications. While wearing the same pair of gloves, RN B proceeded to administer prescribed eye drops in both of Resident #70's eyes and handed her a paper towel. RN B removed the gloves, did not perform hand hygiene, and left the resident's room.
2.During continued observation of medication administration on 01/14/2026 at 9:24 AM, RN B, who had not performed hand hygiene after medicating Resident #70, donned a new pair of gloves. She began preparing the oral and transdermal medications for Resident #47. She placed the oral medications in a medication cup, placed Juven powder (therapeutic nutrition powder) in a water cup and added water to mix the powder with. RN B stirred the Juven powder with a spoon. She then removed the outer packaging from the ordered Nicotine Transdermal patch and wrote the date and her initials on the top of the patch. She proceeded to Resident #47's room. RN B entered Resident #47's room wearing the same pair of gloves and did not perform hand hygiene. While wearing the same pair of gloves, RN B proceeded to peel the backing off of the Nicotine Transdermal Patch and place the patch on the resident's left outer upper arm. Without removing the gloves or performing hand hygiene, RN B handed Resident #47 his oral medications. The resident swallowed his oral medications with water at the bedside. RN B then handed Resident #47 the cup of water with the Juven powder mixed in for the resident to consume and departed the room without performing hand hygiene. Upon returning to the medication cart, RN B removed the gloves and cleansed her hands with alcohol-based hand sanitizer.
During an interview with RN B on 01/14/2026 at 9:30 AM regarding hand hygiene, she stated, We are supposed to wash our hands between residents. When asked if staff were supposed to perform hand hygiene upon entrance and exit of the resident's rooms, RN B stated, Well, we are supposed to do both.
During an interview with the Director of Nursing (DON) on 01/14/2026 at 9:40 AM regarding Enhanced Barrier Precautions and Hand Hygiene during medication administration, the DON stated, We have a PIP [Performance Improvement Plan] on that and we just did training.
A review of the facility's policy titled Hand Hygiene (dated April 2022), revealed:
Policy Interpretation and Implementation: 2. Associates must perform appropriate handwashing procedures under the following conditions: d. before preparing or handling medications; f. before handling clean or soiled dressings, gauze pads, etc.; k. after removing gloves.
A review of the facility's policy titled Infection Control-Transmission-Based Precautions (dated August 2023), revealed:
Procedure: 17. Enhanced Barrier Precautions will be implemented for residents with specific cases that do not require other types of transmission-based precautions but are associated with higher risks of transmission, a. Enhanced Barrier Precautions are to be implemented for residents with the following: ii. Residents with an indwelling medical device or a wound, regardless of infection or colonization status.
A review of performance improvement documentation offered by the facility and dated with an initiation date of 10/15/2025, identified that Infection Control and Antibiotic Stewardship was being reviewed. Education with signature sheets, provided to the field office after the survey, indicated that handwashing education was provided on 10/15/2025 and 11/13/2025. RN B was not listed as having received handwashing education on either 10/15/2025 or 11/13/2025. Thirty-four handwashing competencies were provided to the field office after the survey. The Date line at the top of each form had been whited out. Twenty-six of thirty-four forms had a hand-written date entered on the date line of either 12/11 or 12/11/25. Eight forms were left with a blank date line after they were whited out. Four forms were incomplete. One form was missing the employee's signature, and two forms were missing a supervisor's signature. RN B was noted to have successfully completed a handwashing competency on 12/11/2025 per the competency forms. Handwashing audits provided to the field office after the survey were noted to have been completed by the Director of Nursing on 10/15, 10/16, 10/17, 10/20, 10/21 and 10/29/2025. RN B was not noted on any of the October 2025 audit forms. A handwashing audit dated 11/5/2025 and 11/19/2025 listed five staff members reviewed including RN B, who was noted as having performed hand hygiene appropriately. A handwashing audit dated 12/17/2025 and 12/31/2025 listed five residents reviewed, and an audit dated 1/7/2026 and 1/14/2026 listed five staff members reviewed including RN B, who was noted as having performed hand hygiene appropriately. On the same date, 1/14/2026, RN B was observed during medication administration, as described above, failing to wash her hands during medication administration for two residents. This indicated that the facility's performance improvement plan was ineffective.

Based on record review and interviews, the facility failed to provide the required beneficiary notices to two (Residents #150 and #151) of three residents reviewed for beneficiary notices, who remained in the facility following termination of their Medicare Part A services, placing them at risk of not receiving the required notice of rights and services and potential financial liability. The findings include:
Record reviews for Residents #150 and #151 revealed that they remained in the facility following termination of their Medicare Part A services, and were not issued the Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN), Forms CMS-10055, by the facility at the time Medicare A coverage ended; information that explained their potential financial liability for items or services that would no longer be covered by Medicare A.
On 01/15/2026 at 9:47 AM, an interview with the Social Services Director (SSD) revealed that he was responsible for coordinating resident discharges; however, he was not responsible for issuing the Notice of Medicare Non-Coverage (NOMNC) or the SNF ABN notification, the MDS (Minimum Data Set) department was responsible. He stated he would follow up to explain the financial liability if the resident or family disagreed with the discharge.
On 01/15/2026 at 2:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) M who reported working in the MDS department for two years, and who confirmed that she was responsible for issuing the notices of discharge to residents discussed in the facility's weekly Patient Driven Payment Model (PDPM) meeting, where NOMNC and SNF ABN notifications were agreed upon. She confirmed that she was responsible for issuing the required SNF ABN notification to beneficiaries that explained potential financial liability, and she reported that when a resident disagreed with the NOMNC or wanted to make an appeal, she notified the Social Services department so they could explain the financial liability potential. She further stated she was unaware that a SNF ABN notification was required.
On 1/15/2026 at 3:05 PM, an interview was conducted with the MDS Coordinator, who confirmed that she assisted LPN M with issuing the NOMNC notifications, and acknowledged the required SNF ABN notification was not being provided to beneficiaries as required.
A review of the facility's policy titled Discharge Planning Process (dated November 2025), revealed:
Intent: It is the policy of the facility to assure that the discharge planning process is implemented in accordance with the State and Federal Regulations. Procedure 2. The facility's discharge planning process will be consistent with the discharge rights set forth at 483.15 (b) as applicable. (Copy obtained)

Based on record review, interviews, and a review of facility documentation, the facility failed to send a copy of the notice of transfer or discharge (Discharge/Transfer Notice AHCA 3120-002 form) to the representative of the Office of the State Long-Term Care Ombudsman's office for four (Residents #126, #150, #151 and #152) of four residents reviewed for discharge requirements. The findings include:A review of the Discharge/Transfer Notice AHCA (Agency for Health Care Administration) 3120-002 Forms issued to Residents #126, #150, #151, and #152 revealed that the forms were incomplete. No date/time of notification was documented for when the notices were provided to the Long-Term Care Ombudsman's office.On 01/15/2026 at 9:47 AM, an interview with the Social Services Director (SSD) revealed that he was responsible for providing notification of transfer and discharge to the local state Ombudsman's office. He stated his process was to send the facility's monthly discharge and transfer list to the Ombudsman's office via fax within the first week of the month following the month the discharges occurred. He was shown the transfer and discharge AHCA 3120-002 forms provided to Residents #126, #150, #151, and #152 at discharge. He confirmed that the section where notice was given to the Local Long-Term Care Ombudsman Council on the AHCA 3120-002 form was blank. He confirmed that he did not send the actual forms to the Ombudsman's office; he only sent the facility's monthly admission/discharge list. On 01/15/2025 at 2:52 PM, an interview was conducted with the MDS (Minimum Data Set) Coordinator/Registered Nurse (RN), who confirmed that her department was responsible for issuing the discharge notifications to the residents, and the Social Services Department was responsible for informing the Long-Term Care Ombudsman's office. She could not confirm when the notifications of residents' transfers/discharges were being provided to the Ombudsman and was unaware of the requirement to send the actual transfer/discharge forms. A review of the facility's policy and procedure titled Discharge Planning Process (dated November 2025), revealed:Intent: It is the policy of the facility to assure that the discharge planning process is implemented in accordance with the State and Federal Regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for one (Resident #66) of four residents reviewed for mobility/positioning, by failing to ensure daily placement of a physician-ordered hand splint. Failure to apply a physician-ordered splint/brace can result in worsening of a contracture, functional decline and increased pain.The findings include:On 01/12/2026 at 11:08 AM, Resident #66 was observed lying in bed with a sheet covering her up to her chin. She held the sheet with her left hand. When greeted, she smiled, shifted her upper body toward the left side of her bed and mumbled, hi. A dark blue colored brace was observed neatly folded on the nightstand located to the right side of her bed. She was asked if she wore the brace that was observed on her nightstand. She shook her head no and sighed before pulling her right arm from under the sheet with her left hand. The fingers on her right hand were stiff and curled toward her palm. She dropped her right hand down to her stomach and stated, see?. She was asked if she received assistance applying and removing her brace. She replied no and cradled her right hand with her left hand close to her chest and began rocking. On 01/14/2026 at 9:40 AM, a second observation was made of Resident #66. She was sitting upright in her bed with her breakfast tray covered on her bedside table. A family member was resting in a reclining chair in the corner of the room. When asked how she was feeling, she tilted her left hand back and forth to motion so/so. When asked if she had her brace on, she pulled her right arm out from under the covers with her left hand, dropped it to her stomach and cradled it with her left hand. The dark blue brace was observed on the nightstand in the same spot as it was on 01/12/2026 at 11:08 AM. The resident's family member reported that they visited her every day, all-day and they had not seen staff helping her with her brace in months. A record review conducted for Resident #66 revealed she was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia/hemiparesis following a cerebral infarction (stroke) affecting her right side. Additional diagnoses included reduced mobility, muscle weakness, and chronic pain syndrome. The most recently completed Minimum Data Set (MDS) quarterly assessment, dated 09/05/2025, revealed that Resident #66 had adequate hearing, unclear speech/mumbled words, and her Brief Interview for Mental Status (BIMS) score was 06 out of 15 possible points, indicating severe cognitive impairment. No behaviors or rejection of care were documented. She was noted with upper impairment to one side (shoulder, elbow, wrist, hand) and for lower extremity impairment (hip, knee, ankle, foot). She used a wheelchair for mobility; she was dependent for toileting; she required substantial/maximal assistance with showering/bathing and upper body dressing. She was dependent on staff for lower body dressing. The Occupational Therapy start date was 08/14/2025. No range of motion or splint/brace assistance was documented.A review of the resident's active Physician's Orders revealed: Pt (patient) to have R (right) resting hand splint on 6-8 hrs. (hours) per day to decrease risk of contracture. RUE (right upper extremity (upper arm) skin checks to be performed before and after. Order date 03/20/2025, active.A review of the December 2025 Medication Administration Record (MAR) revealed that the physician's order for Resident #66 to have a right resting hand splint on 6-8 hours per day, in addition to skin checks before and after, was not listed.A review of the resident's active comprehensive care plan revealed no focus area for the right-hand contracture with splinting or the skin checks before and after use of the brace. On 01/14/2026 at 12:10 PM, an interview was conducted with Certified Nursing Assistant (CNA) P who confirmed that she worked with Resident #66 and was unaware of a splint or brace.On 01/15/2026 at 11:29 AM, CNA I reported that residents who had splints/braces were evaluated and assessed by therapy or a doctor, and then therapy would communicate to the CNAs. She further stated education was provided about when to apply the brace, the length of time it was to remain on, and the shift responsible for the application/removal of the brace. She added, We are responsible for placing them. She confirmed that she was familiar with Resident #66 and confirmed she had never seen a hand brace or splint on her.On 01/15/2026 at 12:15 PM, Licensed Practical Nurse (LPN) G reported her expectations for CNAs when rounding included obtaining vital signs, changing soiled briefs, checking skin condition, and reporting any changes to nursing. She was unable to confirm who was responsible for applying braces/splints, and said she was unaware of any of her assigned residents having a brace. If they did, it would be documented in their chart, and in the physician's orders.On 01/15/2026 at 2:05 PM. Occupational Therapist (OT) F reported that she had worked for the facility for five years, and her responsibilities included screening new admissions, completing assessments, and family and resident education. When she completed an evaluation, she did a full resident chart review, how they move, transfer and strengths. She made recommendations and goals were set related to ADLs to include bathing, dressing, and toileting. She confirmed that Resident #66 was not currently receiving therapy services, but she had worked with her when she was. OT F confirmed that there was an active order for a right resting hand splint and stated restorative nursing or the assigned CNA was expected to place the hand splint when the resident was not active in therapy. On 01/15/2025 at 3:11 PM, an interview was conducted with the MDS Coordinator/Registered Nurse (RN) and LPN E who was responsible for completing the assessments for all of the long-term care residents. LPN E confirmed that she completed the quarterly and annual assessments for Resident #66 and that completing her assessments was a challenge, but she asked yes and no questions, talked to the care team about any changes, and then updated the care plans. This last quarter she reported seeing no changes. LPN E was asked to review Resident #66's active physician's orders for any special devices. She confirmed that there was an active order for a right resting hand splint for 6-8 hours daily. She confirmed that the splint was missed on the quarterly MDS assessment completed on 09/05/2025, and that no comprehensive care plan was developed or implemented. A review of the facility's policy and procedure titled Activities of Daily Living (ADLs/Maintain Abilities) (dated January 2024), revealed:It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff across all shifts and departments, understand the principles of quality of life, and honor and support these principles. The policy interpretation and implementation indicated: 1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities of daily living do not diminish. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to honor a resident's right to make choices regarding accommodations to support safe bed mobility and positioning; specifically, failing to provide requested handrails in a timely manner for one (Resident #136) of 49 residents in the total survey sample. Failure to honor a resident's right to make choices about their care can result in physical injury or psychological distress.The findings include:On 01/13/2026 at 11:45 AM, Resident #136 was observed being pushed in her wheelchair by a staff member back to her room where her daughter was present. Resident #136 reported that she was admitted to the facility last week, and that upon admission, both she and her daughter had asked the Administrator directly for partial bedrails to assist her with positioning while she was in bed. The Administrator's response was that he would look into it, but they had not heard back about it yet. She further stated she was worried about hurting herself because the staff were asking her to grab onto the closet door handle and the side table to reposition herself.On 01/14/2026 at 11:41 AM, Resident #136 was observed seated in her wheelchair with a nasal cannula in place. She was dressed and eating her lunch. No bedrails were observed on her bed. Her daughter was present in the room and reported that she requested to speak with the Administrator yesterday (1/13) and was told he was out of his office. She left a note with the front desk personnel requesting to speak with him. She stated she overheard the Administrator in another resident's room and when he walked by Resident #136's room, she stopped him to ask about the bedrails for her mother's mobility. She stated his response was that he did not have time to address it right now. She stated he entered the room and asked about a telephone that was sitting on the floor but did not provide a response about the bedrails prior to leaving the room, so she planned on leaving another message for him with the front desk. On 01/14/2026 at 12:10 PM, an interview was conducted with Certified Nursing Assistant (CNA) P, who stated the residents with bedrails on their beds received them through the therapy department, and if she received a request for bedrails from a resident, she would notify the nurse.On 01/14/2026 at 12:36 PM, Resident #136's daughter was observed at the reception desk requesting to speak with the Administrator. As the Administrator was turning the corner away from the reception area, he was informed that a family member wanted to speak with him. He continued walking away without acknowledging the request. A medical record review for Resident #136 revealed that she was admitted to the facility for short-term rehabilitation services on 01/06/2026, with a discharge goal to return to the community. Her primary medical diagnosis was Rhabdomyolysis (a condition where damaged muscle tissue breaks down, releasing harmful substances into the bloodstream. Symptoms can include muscle pain and weakness). Additional listed medical diagnoses included generalized muscle weakness, anemia, peripheral vascular disease, and dependence on supplemental oxygen. A review of Resident #136's admission Minimum Data Set (MDS) assessment, dated 01/14/2026, revealed that she had clear speech, could make herself understood, and had the ability to understand others with a Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. She was coded as requiring substantial/maximal assistance for rolling left and right, and partial to moderate assistance with sitting to lying and sitting to a standing position. No mental status changes, behavioral issues or refusal of care were noted. She was noted as using a rolling walker at home prior to admission and there were no limitations noted to her range of motion. A history of falls, muscle weakness and continuous oxygen use were noted. No bedrails were noted. There was no MDS question that asked the resident whether she would like bedrails for mobility assistance. There was no place on the MDS assessment to document this information. A review of the Physical Therapy Evaluation and Plan of Treatment was conducted for the certification time period of 1/7/2026 - 2/3/2026. The evaluation noted that the resident previously lived alone in a single-story home and was moderately independent with all functional mobility to include ambulating with a front-wheeled walker and driving. The following baseline information was documented as of 1/7/2026:Baseline: 30-second sit-to-stand - Patient is unable - Requires use of handsBaseline: Roll left to right - Partial/moderate assistanceBaseline: Ambulation was not attempted due to medical conditions or safety concerns.Patient was admitted to the hospital on [DATE] for right lower back pain when moving her right leg. Patient now presents with a decline in strength, balance, endurance and safety awareness during bed mobility, transfers and ambulation.Precautions: Fall risk, anxious, self-limiting, Hoyer (mechanical lift)Prior Therapy: Yes, at hospital and inpatient rehab facilityPrior Living: Patient resided in a private residencePrior Equipment: Front-wheeled walker, wheelchair, shower chair, grab bars, oxygen concentrator, portable oxygenPrior Cognitive Assistance: IndependentPrior Device Use: WalkerThe evaluation indicated that the resident was previously independent with bed mobility, transfers and ambulation prior to hospitalization.History of Falls: The evaluation indicated that Resident #136 had fallen three times in the last year.Does the patient feel unsteady when standing? Yes.Does the patient worry about falling? Yes.Impaired lower extremity strength bilaterally (both legs)Decision making ability for routine activities: IndependentA Request for Therapy Evaluation, dated 1/14/2026 (third day of the survey), was reviewed. The following information was included:The form's line for Nursing Assessment indicting that the resident had a recent change in the ability to _______ (line left blank) (ADL/functional activity) was not filled in; however, the Least restrictive devices for positioning was checked off with a handwritten entry stating, Mobility bar for bed. The therapist who authored the form wrote, Patient assessed for mobility bar for safety and improve indep. w/ADLs (independence with activities of daily living) Pt sup w/mobility bar. It was signed on 1/14/2026. (Copy obtained)On 1/15/2026 at 12:54 PM, during an interview with Licensed Practical Nurse (LPN) K/Unit Manager for the Short-Term Rehabilitation Unit, she stated residents with bedrails in place received them through an approval process with the therapy team who evaluated residents for their mobility needs and an assessment for use without harm. She further stated bedrails were then ordered, care planned and placed on the bed by the maintenance department staff. She denied being aware of any requests for bedrails made for Resident #136. On 01/15/2026 at 2:12 PM, an interview with Occupational Therapist (OT) F revealed that residents could have bedrails placed after being assessed by the nursing and therapy departments. The residents were evaluated for bed mobility during their initial evaluation when they asked about prior use of bedrails to determine the need. On 01/15/2026 at 2:36 PM, an interview was conducted with Physical Therapist (PT) D who completed Resident #136's Physical Therapy Evaluation and Plan of Treatment during the certification time period (1/7/2026 - 2/3/2026). PT D acknowledged that a request for bedrails was made by the resident for safety and positioning at the time of the evaluation on 1/7/2026, but she was denied because she did not use them at home. On 01/15/2026 at 3:27 PM, an interview with the Administrator was conducted. He was asked how residents and their family members were able to reach him and he replied, My contact information is available on my business cards, or through any of the managers or the receptionist. I have an open-door policy and can be contacted through email, voicemail, or staff directly, and when I'm not immediately available, I will call them back typically the same day or the next day. He was asked if he knew about Resident #136's request for bedrails. He said yes, he was notified the day after she was admitted to the facility, and he consulted with the Director of Nursing (DON), but he failed to follow up with the resident and family. He further stated, After the family member tracked me down in the hallway, I just had them installed today. This was something that just went by the wayside and I probably should've followed up sooner than I did, but the rails are in place now. (Nine days after the resident was admitted and requested the bedrails)A review of the facility's policy titled Resident Rights (dated December 2025), revealed on page 5, number 35 that, The resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to 1) ensure each resident received adequate supervision to prevent accidents, failed to implement appropriate interventions, and failed to monitor the effectiveness of interventions to prevent falls for one (Resident #4) of three residents reviewed for accidents and hazards, and 2) failed to provide an environment free of hazards for one resident (Resident #8) in a total sample of 19 residents.
The findings include:
1) A review of Resident #4's medical record revealed an admission date of 7/6/2021, with a primary diagnosis of cerebral infarction. The secondary diagnoses included dementia and fracture of the right wrist and hand. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points, indicating moderate cognitive impairment. Resident #4 required supervision with most activities of daily living (ADLs). She was continent of bowel and bladder and had a history of falls in the facility.
On 3/28/2022 at 11:45 a.m., Resident #4 was observed lying in bed with her eyes closed. A splinting device was observed to her right forearm and wrist.
On 3/31/2022 at 9:58 a.m., an interview was conducted with Resident #4 in her room. She was sitting in her wheelchair. She was alert and oriented to person and was a poor historian. She was wearing a splinting device to the right wrist. She was not wearing her glasses. Resident #4 was initially unable to recall whether she had fallen in the facility. However, when asked about the splinting device on her right wrist, Resident #4 stated, Well, I fell and broke it. Resident #4 was unable to expand on the circumstances of the fall. When asked if she was able to move her fingers, Resident #4 stated, They are so stiff. The whole hand is stiff. The resident's call light was observed clipped to the left side of her bed. When asked what the call light button was for, the resident stated, Oh, it's a night light. When asked how she called for staff assistance, the resident stated she did not know. Resident #4 was unable to recall whether facility staff had spoken to her about her fall risk factors and interventions. During the interview, an observation of the room was made. There was no bedside commode or reaching device observed in the resident's room.
A review of the nursing progress notes revealed an entry date 2/11/2022 at 8:35 a.m. which indicated Resident #4 had sustained a recent fall. The nurse noted Resident #4's right wrist was swollen purple and hard to move. The nurse described Resident #4 as guarding her right wrist and indicated Resident #4 was unable to hold cup of water for morning medications. Resident #4 requested pain medication for pain which she rated an 8/10. The Nurse Practitioner was notified, and an x-ray of the right wrist was ordered. (Photographic evidence obtained)
An x-ray of Resident #4's right wrist was reviewed which identified an acute, mildly displaced, impacted transverse distal radial fracture. (Photographic evidence obtained)
A provider progress notes by the Nurse Practitioner dated 2/11/2022 indicated the fall occurred on 2/10/2022 at approximately 7 p.m. in the resident's room. She was sitting in her wheelchair and toppled out using her right arm to break the fall. An x-ray was ordered by the Nurse Practitioner which revealed an acute, mild displaced, impacted transverse distal radial fracture. The Nurse Practitioner ordered an orthopedic consult Monday morning. (Photographic evidence obtained)
A nursing progress note dated 2/11/2022 at 5:59 p.m. indicated the results of the x-ray were shared with Resident #4's daughter and that the daughter was made aware that the resident did not want to be transferred to the emergency room. (Photographic evidence obtained)
A nursing progress note dated 2/12/2022 at 1:16 a.m. indicated the resident was up throughout the night and was non-compliant with assistive devices. The note indicated that a sling was in place, but the resident continued to use her right hand. Resident #4's right wrist and hand presented with significant swelling and bruising, and the resident complained of 10/10 pain. The note did not indicate that supervision was increased to limit worsening of the injury. (Photographic evidence obtained)
A nursing progress note dated 2/13/2022 at 1:08 a.m. indicated Resident #4's daughter came to visit and insisted that the resident be sent to the emergency room for evaluation of the right wrist. The resident returned from the hospital with a splint on right wrist to just below right elbow. The resident was ordered to follow up with orthopedics at a previously scheduled appointment. (Photographic evidence obtained)
A therapy Discharge summary dated [DATE] indicated discharge recommendations for resident to use a wheelchair for mobility and therapy to assess the resident at a new facility. The note read, Pt [patient] initially was making progress towards goals however patient had fall midway through assessment period and fractured right wrist. POC [plan of care] transitioned to training patient on functional mobility without use of R UE [right upper extremity] which has made tasks more challenging. Pt also experienced increased dementia symptoms and agitation further complicating recent progress. POC had transitioned to mobility training without use of UE [upper extremity] however therapist notified patient will be transferring to another LTC [long term care] facility for increased supervision. (Photographic evidence obtained)
On 3/31/2022 at 1:35 p.m., an interview was conducted with the Physical Therapist. He was asked whether any therapy services had been provided for Resident #4 after her wrist fracture. He explained that the resident was planning to be discharged from therapy anyway because of her advancing dementia. She didn't seem like she was making much progress. When asked to clarify whether the resident would benefit from therapy services related to the wrist fracture, he stated, We were waiting for the splint to come off.
On 3/31/2022 at 1:41 p.m., an interview was conducted with Occupational Therapist. She explained that Resident #4's ability to follow directions was about 25%. She stated, We have repeatedly educated the resident for some sort of carryover. It's difficult to redirect her. She doesn't believe she has deficiencies. She has very poor safety awareness.
A review of an orthopedic consult dated 3/15/2022 indicated recommendations for a wrist brace at all times, Occupational Therapy and Physical Therapy for fingers range of motion, weight-bearing as tolerated to right hand with brace on and follow up in three weeks. (Photographic evidence obtained)
Further review of Resident #4's medical record revealed approximately 19 other falls. A nursing progress note dated 7/7/2021 at 1:38 p.m. indicated Resident #4 was found on the bathroom floor with her brief off and stool on the ground. Resident #4 reported that she had to go and forgot how to press the call light. Resident #4 reported hitting the back side of her head. The nurse had the resident practice using the call light to ensure she knew how to use it. Resident #4 voiced that she might forget but will use the call light if she needs help. (Photographic evidence obtained) During an interview with the Director of Nursing (DON) on 3/31/2022 at 11:25 a.m., she explained that the cause of the fall was tiredness, and that the resident's dementia medication was changed from day shift to night shift.
A nursing progress note dated 7/8/2021 at 1:25 a.m. indicated Resident #4 was observed on floor in her bathroom during care rounds. Resident #4 stated, I had to go to the bathroom. She had taken off her brief and used her rollator (a walking frame that has wheels on the bottom) to ambulate to the restroom. The nurse educated the resident on the use of her call light. Review of the comprehensive care plan revealed an intervention dated 7/8/2021 to place a bedside commode in the resident's room. (Photographic evidence obtained)
On 3/31/2022 at 11:00 a.m., an observation of Resident #4's room was conducted with the Director of Nursing. She confirmed that there was no bedside commode in the room. During an interview with the DON on 3/31/2022 at 11:25 a.m., she stated she was not sure of the cause of the fall but confirmed that a bedside commode should have been placed in the resident's room.
During observations of Resident #4's room on 3/28/2022 at 11:35 a.m., 3/29/2022 at 12:45 p.m., 3/30/2022 at 5:20 p.m., and 3/31/2022 at 9:58 a.m., a bedside commode was not noted in the resident's room or restroom.
A nursing progress note dated 7/10/2021 at 4:01 a.m. indicated Resident #4 was on the floor in her bathroom. The resident stated she just had to go to the bathroom. Resident #4 stated she sat on the ground given her gown was under her feet. Resident #4 was provided with non-skid socks and a shorter robe. The note indicated the resident was and is continually advised to use her call light for assistance for ambulation. A review of the comprehensive care plan revealed an intervention dated 7/10/2021 which directed staff to encourage proper footwear. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she was asked whether the facility had considered establishing a bowel and bladder pattern for Resident #4 and proactively assisting her to the restroom to avoid unassisted trips to the restroom. The DON stated she was unsure and would look into it.
A nursing progress note dated 7/27/2021 at 5:39 p.m. indicated Resident #4 was trying to push her room door closed and fell to the floor. The note indicated the fall was witnessed by staff. The physician was notified, and the resident was transferred to the hospital for evaluation. A review of the comprehensive care plan revealed an intervention dated 7/28/2021 which directed staff to remind the resident to call for assistance. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., the DON explained she was not sure of the cause of the fall and confirmed that the intervention was to remind the resident to call for assistance with transfers.
A nursing progress note dated 7/31/2021 at 1:41 p.m. indicated Resident #4 was standing in the doorway and tripped over her feet and fell. The note indicated the fall was witnessed. A review of the comprehensive care plan revealed no updated interventions for this fall. (Photographic evidence obtained) During interview with the DON on 3/31/2022 at 11:25 a.m., she explained that the resident was provided with her grandpad which she explained was an electronic tablet. The DON was unsure of what the resident was doing at the time of the fall or how the facility determined this intervention was suitable for Resident #4.
A nursing progress note dated 8/14/2021 at 6:27 p.m. indicated Resident #4 was noted on the floor between the bed and air conditioning unit. The resident stated she was trying to get up to go vomit and felt dizzy and slid off the bed. The note indicated neuro checks were initiated but the resident refused after having two sets of vital signs assessed. Review of the comprehensive care plans revealed an intervention dated 8/14/2021 which directed staff to obtain orthostatic blood pressures for three days. (Photographic evidence obtained) Review of the medical record revealed no documented orthostatic blood pressures. During interview with the DON on 3/31/2022 at 11:25 a.m., the DON explained that the cause of the fall was likely hypotension and confirmed that orthostatic blood pressures were to be obtained and documented. She was not able to locate the orthostatic blood pressures in the medical record.
A nursing progress note dated 9/27/2021 at 7:48 a.m. indicated Resident #4 was observed kneeling on the side of the bed closest to the window. The resident stated she rolled out of bed. The note indicated neurological checks were initiated and a new order was obtained to monitor for skin and mental status changes over the next 72 hours. A review of the comprehensive care plan revealed no updated interventions for this fall. (Photographic evidence obtained) During interview with the DON on 3/31/2022 at 11:25 a.m., the DON explained that the Nurse Practitioner had been notified of the fall and ordered a cardiology consult. She added that cardiology recommended a [NAME] Monitor and stated the procedure had been completed. She was unable to locate the [NAME] Monitor findings in the medical record and stated she would look for them. The facility was unable to produce the findings of the [NAME] Monitor as of the time of survey exit.
On 4/5/2022 at 12:26 p.m., email correspondence was received from the facility Administrator which read, I just wanted to follow up with you in regard to the [NAME] monitor. The resident at the time of the order was Covid positive, which at that time cardiology did not find was necessary to complete the [NAME] monitor due to causing inaccuracy.
Review of a provider progress note by the Nurse Practitioner dated 9/28/2021 indicated the resident was seen after report of a fall. The assessment and plan indicated gait instability with a plan to continue working with therapy for spatial awareness and strength training. A second diagnosis was noted for tachycardia with a plan to consult in-house cardiology. (Photographic evidence obtained)
A nursing progress note dated 10/16/2021 at 4:45 p.m. indicated Resident #4 fell to the ground on her right side hitting the right area of her head above her eye. The resident indicated she was feeling pain in her right hip. An order was obtained to transfer the resident to the hospital. Review of the comprehensive care plan revealed an intervention dated 10/16/2021 which directed staff to remind resident to use her walker. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she explained that the cause of the fall was the resident's impulsiveness, and that staff reminded the resident to use her walker for ambulation.
A nursing progress note dated 10/17/2021 at 4:23 a.m. indicated Resident #4 returned from the hospital with a diagnosis of facial and hip contusion. (Photographic evidence obtained)
A nursing progress note dated 10/23/2021 at 10:14 p.m. indicated Resident #4 was found sitting in her bathroom on the floor. The resident stated she lost her balance while trying to get to the toilet. A skin tear was observed to the left knee. A review of the comprehensive care plans revealed an intervention dated 10/23/2021 which directed staff to draw labs. (Photographic evidence obtained) Review of the medical record revealed no lab results from 10/23/2021. During an interview with the Director of Nursing (DON) on 3/31/2022 at 11:25 a.m., the DON confirmed that the fall response intervention was to obtain labs. She explained that the labs had been drawn and that she would need to look for them. When asked whether the facility had increased supervision or implemented any other immediate safety interventions as a response to this fall, the DON again stated, We ordered labs. The facility had not been able to produce the lab results as of the time of survey exit on 3/31/2022. On 3/31/2022 at 9:21 p.m., email correspondence was received from the Administrator which contained an attachment of Resident #4's lab results. There were no labs results for 10/23/2022.
A nursing progress note dated 11/20/2021 at 4:17 a.m. indicated Resident #4 was observed sliding off the bed down to the floor and onto her buttocks. Her walker was noted to be in front of the bed. The resident was assisted to toilet and then was assisted back to bed where she was then resting comfortably. A review of the comprehensive care plan revealed no updated interventions related to this fall. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she explained that the intervention for the fall was to adjust the Resident's thyroid medication and provide melatonin for sleep. Review of the physician orders revealed the medications were adjusted on 11/15/2021 and 11/29/2021.
A nursing progress note dated 11/25/2021 at 6:01 a.m. indicated Resident #4 sustained an unwitnessed fall with head injury. The resident was observed lying on the floor next to the bed with a significant amount of blood noted at right side of head. The resident was transferred to the hospital for evaluation and treatment. A nursing progress note dated 11/30/2021 5:56 p.m. indicated the resident was readmitted to the facility with a diagnosis of pneumonia. A review of the comprehensive care plan revealed no updated interventions related to this fall. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she confirmed that no new safety interventions had been implemented.
A nursing progress note dated 12/11/2021 at 5:13 a.m. indicated Resident #4 was noted lying on the floor with a skin tear to the right brow which presented with significant bleeding. The resident was transferred to the emergency room for evaluation and treatment. She was placed on continuous supervision until transfer. A review of the comprehensive care plan revealed an intervention dated 12/11/2021 which directed staff to reiterate the importance of using a walker to ambulate. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she confirmed that no immediate safety interventions had been implemented.
A nursing progress note dated 1/15/2022 at 2:57 a.m. indicated Resident #4 was observed sitting on the floor in the bathroom in front of the shower chair. The resident stated she lost her balance. A review of the comprehensive care plan revealed no updated interventions for this fall. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., she confirmed that there were no new safety interventions implemented on the resident's care plan. She stated, The nurse provided education on safety measures and educated staff to remind the resident to use her walker.
A nursing progress note dated 1/26/2022 at 5:11 a.m. indicated Resident #4 alerted nursing staff by calling out. She was observed in seated position on the floor in doorway to room with the door closed. Her walker was near her bedside and was out of reach of the resident. A round raised area was noted to right side of the resident's head with purple discoloration. Resident #4 stated she was leaning forward to get something and lost her balance. Resident #4 requested to go to the hospital for evaluation and treatment. A review of the comprehensive care plan revealed an intervention dated 1/26/2022 which directed staff to provide with reacher. During observations of Resident #4's room on 3/28/2022 at 11:35 a.m., 3/29/2022 at 12:45 p.m., 3/30/2022 at 5:20 p.m., and 3/31/2022 at 9:58 a.m., a reaching device was not observed in Resident #4's room, restroom, or closet. During an interview with the DON on 3/31/2022 at 11:25 a.m., the DON confirmed that the intervention the facility implemented was to provide the resident with a reaching device.
A nursing progress note dated 1/27/2022 at 2:26 a.m. indicated that at approximately 1:20 a.m., the nurse heard a thud and observed resident on the floor in the doorway of her room. She was not using her walker. The resident stated she hit her left knee. The knee was noted to have immediate signs of swelling and bruising. Frequent gentle reminders provided. Staff continues to make frequent rounds. A review of the comprehensive care plan revealed an intervention dated 1/27/2022 which directed staff to consult psychiatry for insomnia but did not reflect any immediate safety interventions. (Photographic evidence obtained) During an interview with the DON on 3/31/2022 at 11:25 a.m., the DON confirmed that the facility recommended a psychiatry referral but did not implement any immediate safety interventions.
A nursing progress note dated 2/1/2022 at 1:23 a.m. indicated that Resident #4 was heard calling for help. The resident was observed lying face down with walker in front of her. Resident #4 was advised to reapply nonskid socks back to feet and she refused. Discoloration was noted to the left side of the resident's forehead. A review of the comprehensive care plan revealed an intervention dated 2/1/2022 which read, educated family on importance of having rollator and asked to return it to facility. There were no immediate safety interventions noted. (Photographic evidence obtained)
A nursing progress note dated 2/10/2022 at 3:27 p.m. read, Resident discussed in risk meeting, continues to be on fall protocol, resident has an unsteady gait, has behaviors of aggressions and yelling out, resident is able to be redirected. Family aware of resident's behavior. Resident reminded to use her walker.
On 3/30/2022 at 1:10 p.m., an interview was conducted with the Director of Nursing (DON). She described Resident #4 as impulsive with fluctuating levels of cognitive impairment. The DON confirmed that Resident #4 had sustained a fall resulting in a fracture of her right wrist. When asked for evidence of investigations for each fall, the DON explained that the facility had initiated a performance improvement project for the management of falls on or around 2/18/2022. She stated, there probably isn't much information before that, I just recently took over being the Risk Manager.
According to the Agency for Healthcare Research and Quality (AHRQ) (Accessed on 3/30/2022 at 2:30 p.m.), an immediate response should help to reduce fall risk until more comprehensive care planning occurs. Therefore, an immediate intervention should be put in place by the nurse during the same shift that the fall occurred. When investigation of the fall circumstances is thorough, it is usually clear what immediate action is necessary. For example, if the resident falls on the way to the bathroom because of urgency and poor balance, interventions related to toileting and staff assistance would be appropriate.
2. A review of Resident #8's medical record revealed an admission date of 1/21/2022, with diagnoses that included syncope and collapse, stiffness of the right shoulder, metabolic encephalopathy, difficulty walking, major depressive disorder, vascular dementia, anxiety disorders, and history of fall.
A review of the Resident #8's admission MDS assessment dated [DATE] revealed a BIMS score of 10 out of a possible 15 points, indicating moderate cognitive impairment. Resident required supervision for bed mobility, transfer, and toileting. Resident had a history of fall in the last month prior to admission.
During an initial tour of Resident #8's room on 3/28/2022 at 12:00 p.m., a broom, mop and area rug were observed near in the bathroom. (Photographic evidence obtained)
On 3/28/2022 at 12:10 p.m., an interview was conducted with Resident #8. She stated the area rug was on the bathroom floor because the floor was very slippery during showers. She explained that she was not supervised and didn't want to fall.
A review of the resident's care plan revealed a focus area for falls related to weakness, psychotropic medication use, impaired cognition, diagnoses osteoporosis, dementia, and depression. Interventions included keep environment safe, place call bell within easy reach, and assist for toileting and transfer as needed.
On 3/30/2022 at 9:43 a.m., Resident #8 was observed in the bathroom unsupervised using a curling iron near the sink. During the observation, Resident #8 stated, she was getting ready for bible study and had to do her hair. When asked if she was allowed to use the curling iron. She stated, Staff have seen it and they have not said anything.
On 3/30/2022 at 11:10 a.m., a tour of Resident #8's room was conducted with the DON. Upon entering the resident's bathroom, the DON, shook her head and stated, Wow. She confirmed that the rug, broom and mop should not be in the resident's bathroom. When asked if the resident had an assessment to use of the curling iron. She stated the resident was independent with ADLs per therapy assessment and therefore she could use the curling iron. When asked for the facility's policy, she stated that there was no policy on accidents.
On 3/31/2022 at 10:45 a.m., another tour of Resident #8's room was conducted with Employee A, Licensed Practical Nurse (LPN). The resident was lying in bed. A visit to the bathroom revealed the area rug was still in the bathroom. (Photographic evidence obtained). When the resident was asked if she still had her curling iron, she replied, Yes, it's in my dresser. She went onto explain that she used it weekly. When she was informed of the hazard, she replied, The staff see me use it and no one has ever said anything. She once again confirmed that she took her showers independently and therefore needed the area rugs. During the observation, Employee A, LPN stated, she was not aware Resident #8 had a curling iron or area rug. She acknowledged that the items were a hazard and due to resident's comorbidities, she should be supervised while using them. Employee A, LPN stated that she would talk to the family to have the items removed.
A review of the occupational therapy (OT) evaluation dated 3/3/2022 revealed the following: Resident #8 was referred to skilled occupational therapy from nursing due to right shoulder pain. Resident has pain that interferes /limits functional activity. Resident was discharged from occupation therapy due to meeting maximum potential. The discharge assistance revealed morning and evening assistance from caregiver.
During an interview with Employee C, Occupational Therapist on 3/31/2022 at 10:53 a.m., she stated that the OT evaluation dated 3/3/2022 did not include the use of area rugs or curling iron. She explained that the evaluation assessed the resident's dependence with ADLs. She further explained that the nursing staff should supervise the resident during care and the rug was a fall hazard.
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Based on observation, record review, staff interviews, and facility policy and procedure, the facility failed to ensure a peripherally inserted central catheter (PICC) used for the administration of intravenous fluids was maintained in accordance with professional standards of practice, failed to develop a comprehensive person-centered care plan regarding the use of intravenous (IV) antibiotic, and failed to obtain physician's order for a PICC line for one (Resident #48) of one resident receiving intravenous antibiotic, from a total sample of 19 residents.
The findings include:
A review of Resident #48's medical record revealed an admission date of 3/9/2022, with a primary diagnosis (dx) of cellulitis (a serious bacterial infection of the skin) of the right lower limb. The secondary diagnoses included lymphedema, cellulitis of the left lower limb, cellulitis of other sites, and need for assistance with personal care. A review of the physician's order dated 3/9/2022 revealed, Piperacillin - tazobactam recon solution 3.375-gram, 50 ml intravenous [DX: Cellulitis of other sites] every 6 hours; 05:00, 11:00, 17:00, 23:00 with end date of 3/24/2022. A second physician's order revealed May d/c PICC (peripherally inserted central catheter line) [Dx: Cellulitis of right lover limb] on 3/29/2022. (Copies obtained)
A review of the resident's care plan with start date of 3/21/2022 revealed a problem category of Health Related Complications. Resident #48 has a Peripherally Inserted Midline. Approaches included check site every 8 hours for signs and symptoms of inflammation/infection, dressing changes as ordered, ensure site is lean and protected with sterile dressing, label infusion lines with dates of renewal, and observe for signs of bleeding at site entry. The care plan did not include any documentation concerning orders for the IV-line initiation or maintenance. (Copies obtained)
During a tour of the facility on 3/28/2022 at 11:28 AM, Resident #48 was observed in his room lying in the bed. There was an empty IV bag hanging on the pump at the bedside. An observation of the resident's IV site dressing was dated 3/8/2022. The site area was soiled with blood and the insertion site was not visible. (Photographic evidence obtained)
An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 3/31/2022 at 1:40 PM. When asked about the facility's policy regarding IV line changes. She stated, she was not sure but the IV dressing should be changed at least every 72 hours.
An interview was conducted with Employee B, Registered Nurse (RN)/Infection Control Specialist (ICS) on 3/31/2022 at 1:40 PM. When asked about the facility's policy regarding IV line changes. She stated, she was not sure what the facility's protocol was for the IV-line dressing. She explained that she did not do the antibiotic stewardship but that the IV dressing change should be conducted every 72 hours and as needed.
During an interview with the Director of Nursing (DON) on 3/31/2022 at 2:25 PM, she stated that she was training the ICS on antibiotic stewardship as she was new to the role. She explained that residents admitted with antibiotic orders or have new antibiotic orders are reviewed during the next day's clinical meeting to ensure the antibiotics had a diagnosis and stop date. She was asked how often the PICC line dressing was supposed to be changed, she said, Every 7 days. She confirmed that Resident #48 did not have a physician order for PICC line insertion and the resident's IV dressing had not been changed from 3/8/22 to 3/28/22. She stated that an in-service for nurses was initiated.
A review of the facility's Vascular Access Devices and Infusion Therapy Procedures and Dressing Change for Vascular Access Devices with effective date of 08/21, included the following: Purpose: To prevent local and systemic related to the IV catheter. Policy: 1. Short peripheral catheter dressing are changed every 7 days or when the integrity of the dressing is compromised. Change the dressing if moisture, draining, or blood is present of for further assessment if infection is suspected. 2, Central venous devices and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment of infection is suspected. 4. Initial dressings after catheter placement will be changed PRN if saturated, and 24-48 hours post insertion of midlines, PICCs, or other central venous access devices if gauze is present under the dressing and/or there is blood/drainage under the dressing. Initial dressing with BioPatch at the site may be left in place for 7 days unless the Biopatch is saturated, or the dressing is otherwise compromised. 18. Suggested charting included: site assessment, prep used, type of dressing, Catheter securement (integrity of sutures, other devices), and resident response to procedure. (Copy obtained)
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure all professional staff was licensed in accordance with applicable State laws for one (Employee A) of ten employee records reviewed. The employee was listed on the employee roster and working as a licensed practical nurse (LPN), the employee's license status was listed as application in process. This practice has the potential to affect all 50 residents present in the facility at the time of the survey.
The findings include:
Record review of the list of staff with position and hire dates documented Employee A was listed as an LPN and the date of hire was [DATE].
Review of the Florida Department of Health license verification website https://mqainternet.doh.state.fl.us/MQASearchServices/HealthCareProviders revealed Employee A's LPN license was null and void and expired on [DATE]. (Copy obtained)
Review of the Agency for Health Care Administration (AHCA) background screening form on [DATE] revealed Employee A's hire date was [DATE] and her current LPN license stated was listed as APPLICATION IN PROCESS. Employee A's previous LPN license revealed an original date of [DATE], with an expiration date of [DATE]. Her license status read, NULL AND VOID.
During an interview with the Administrator on [DATE] at approximately 3:30 PM, she stated that a licensure check was completed for Employee A, and she had a valid license in Ohio. She explained that Employee A was hired as a Patient Care Attendant (PCA) and then moved into the LPN position once her application for licensure was submitted. At that time, the Administrator, and the Director of Nursing (DON) were told that the licensure application had not been approved by the State of Florida. Therefore, Employee A was not currently licensed as an LPN in the State of Florida.
A review of timesheets provided by the Staffing Coordinator, revealed Employee A started working in the facility as an LPN on [DATE].
During an interview with Employee A on [DATE] at 4:38 PM, she stated, she had previously lived in Florida and had a valid license in Florida. When she moved to Ohio, she did not renew her license in Florida. She returned to Florida in August of 2021 and applied for her nursing license in September of 2021. She messed up the application by selecting the wrong option. She received an e-mail that told her that there was an issue with her application. She had applied for a multi-state license but did not fill in the information for multi-state. She explained that she intended to apply for just the Florida license, but the paperwork was on her desk at home, and it had not been submitted yet. When asked what her duties included, Employee A replied, I do medication administration, answer call lights, and provide patient care.
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