Inspection·April 22, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notices for the resident. The facility provided one notice dated 12/2/20. The notice did not include the name of the resident's representative, a reason for his discharge or transfer, the date that the notice was given to the resident/legal guardian/representative, or the date the notice was given to the Local Long-Term Care Ombudsman Council. The facility did not provide the notice for the transfer on 12/31/20. 2. A review of Resident #43's Resident Census revealed an original admission date of 1/5/20 and multiple discharges/hospitalizations. The facility provided Resident #43's Nursing Home Transfer and Discharge Notices which revealed: - 1/12/20 - the form did not include the location to which the resident was transferred or discharged to, the effective date, the reason for discharge or transfer, the date that the resident, physician, and Nursing Home Administrator/Designee signed the form, and the date the notice was provided to the LTCOC. - 4/27/20 - the form did not include the location to which the resident was transferred or discharged to, the date the notice was given, the effective date, the reason for discharge or transfer, and the date the notice was provided to the LTCOC. - 5/20/20 - the form did not include the complete information for the location to which the resident was transferred or discharged to, the effective date, the reason for discharge or transfer, the date that the resident (documented as refused to sign), physician, and Nursing Home Administrator/Designee signed the form, and the date the notice was provided to the LTCOC. - 6/3/20 - the form did not include the complete location to which the resident was transferred or discharged to, the reason for discharge or transfer, the date that the resident and physician signed the form, and the date the notice was provided to the LTCOC. - 8/17/20 - the form did not include the effective date, the reason for discharge or transfer, the date that the physician signed the form, and the date the notice was provided to the LTCOC. - 10/2/20 - the form did not include the reason for discharge or transfer, the date that the physician, and Nursing Home Administrator/Designee signed the form, the date the notice was provided to the LTCOC, and the notice was signed by Staff Member E, Licensed Practical Nurse (LPN) as the resident/ resident representative. - 12/18/20 - the form did not include the date the notice was given, the effective date, the reason for discharge or transfer, and the date the notice was provided to the LTCOC. 3. A review of Resident #114's closed medical record revealed a discharge date of 3/4/2021. A review of SBAR communication form dated 3/4/21 revealed Resident # 114 was sent to the emergency room for evaluation due to extreme weakness and altered mental status. A review of the Nursing Home Transfer and Discharge Notice dated 3/4/2021 revealed the following areas were not completed: resident representative, reason for discharge or transfer, the date the notice was given to resident, legal guardian or representative and LTCOC. During an interview with Staff D, Unit Manager (UM), on 4/22/21 at 2:15 p.m. the UM confirmed that she filled out the form, but may have been in a hurry to complete it. She stated that the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 2 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 son was notified of the transfer, and it was documented on the SBAR. Level of Harm - Minimal harm or potential for actual harm On 4/22/2021 at 4:40p.m, the DON stated that she will have to get the Nursing Home Administrator (NHA) to provide the answer of why the Nursing Home Transfer and Discharge Notice information was not completed. Neither the DON nor the NHA returned to provide answers. Residents Affected - Some Record review of the facility policy and procedure titled, Transfer or Discharge Notice, last revised December 2016 revealed: 2. Under the following circumstances, the notice will be given as soon as it is practical but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. f. An immediate transfer or discharge is required by the resident's urgent medical needs 3. The resident/ or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge b. Effective date of the transfer or discharge c. The location of which the resident is being transferred or discharged FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 3 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to provide a Bed Hold Policy prior to transfers for two (#33 and #43) of three residents sampled for hospitalizations. Findings included: 1. Record review for Resident #33 revealed a SBAR dated 12/2/20 indicated Resident #33 began vomiting and feeling weak and an order was received by the provider to send the resident to the emergency room (ER). An admission observation, dated 12/5/20, identified Resident #33 returned to the facility at 12:04 a.m. by an ambulance stretcher. A SBAR dated 12/31/20 indicated the facility received an order to send the resident to the ER due to fever and being non-responsive. On 1/3/21 at 10:54 p.m., an admission observation was documented to indicate the resident returned to the facility. A review of Resident #3's face sheet revealed Medicaid was pending as the primary payer, that the resident was his own responsible party, and his spouse was the emergency contact. A request was made, on 4/21/21, to provide all of Resident 33's Bed Hold notices. The facility provided the Bed Hold notice for 10/24/20 (the date of admission) and one dated 12/4/20 (the day the resident returned from the 12/2/20 hospitalization). The facility did not provide any further bed hold notices for Resident #33. 2. A review of Resident #43's Resident Census revealed he was admitted to the facility on [DATE] with multiple readmissions following hospital leaves and discharges. A review of Resident #43's Face Sheet revealed the payer source was Medicaid and a family member was listed as the emergency contact and responsible party. A review of the Bed Hold policies provided as requested for 2020, did not indicate Resident #43's responsible party received a written bed hold policy at the time of or within 24 hours of the resident's transfer on the following dates: - 4/29/20 (discharge - return expected); - 8/5/20 (discharge - return expected); - 9/25/20 (discharge) - 12/1/20 (discharge) - 12/18/20 (discharge) Continued review of Resident #43's electronic and physical clinical record revealed the resident transferred to the hospital on 1/26/21 for low hemoglobin and returned on 2/3/21, and the resident transferred to the hospital on 3/23/21 for chest pain and returned on 3/26/21. The clinical record was void of documentation to indicate that the resident's representative received a Bed Hold Policy for the 1/26/21 and 3/23/21 hospitalizations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 4 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm During an interview, on 4/20/21 at 3:47 p.m. with Staff Member A, Registered Nurse (RN), she stated she does not send a bed hold policy with the resident during a transfer to the hospital. Staff Member C, Licensed Practical Nurse (LPN), stated that at the time of admission a bed hold was signed by the resident/representative and if the resident stays at the hospital for a length of time, the nurse managers contact the family and have the bed hold signed. Residents Affected - Few On 4/20/21 at 3:54 p.m., Staff Member B, Registered Nurse (RN), was interviewed as she had just completed a transfer to the hospital for a resident. She stated they do not send a bed hold policy with the resident. We keep it here and do everything in the computer. On 4/22/21 at 12:42 p.m., the Director of Nursing (DON) was asked whose responsibility it was to fill out a bed hold. The DON asked if she could ask the Nursing Home Administrator (NHA). On 4/22/21 at 1:58 p.m., the Social Services Director (SSD) stated the Bed Hold was her responsibility if the resident was going home, and nursing was responsible if the resident was transferred to the hospital. On 4/22/21 at 4:39 p.m., Staff Member F, Admissions Director, stated she sends out the Bed Hold notices. The staff member reported that she does not send out a bed hold notice if the hospital was holding a resident in observation for a couple of days and were sending them back. A policy for completing and sending the Bed Hold Policy with a resident at time of Transfer or Discharge was requested but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 5 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and observations, the facility failed to ensure four Residents (#26, #49, #64, #84) of four residents sampled received restorative nursing services in order to maintain their ability to perform activities of daily living. Findings Included: 1) During an interview on [DATE] at 2:22 p.m. Resident #26 stated he had not had a shower in 10 days and feels like he gets restorative nursing when he is in the shower but has not received the restorative nursing program he was told he would get. The resident stated he is not progressing forward and wants to go home but is not sure if that will be possible. Review of the care plan problem area dated [DATE] revealed the resident's ADL/restorative nursing program required active range of motion to bilateral upper extremity 6 days per week. Long term goal to increase strength for transfers and wheel chair mobility created on [DATE]. Approach date of [DATE] for bilateral upper extremity using 3 to 4 pound weight and green theraband, all planes as tolerated, once a day from 7 a.m. to 3 p.m. Problem area revealed the resident ADL/restorative nursing program for limited ability to complete sit to stand created on [DATE]. Long term goal to maintain lower extremity strength to reduce risk of decline to perform sit to stand. Approach using grab bar with max assist x 2 or sit to stand transfers using parallel bars with moderate assist x 1, gait belt for safety, once a day from 7 a.m. to 3. p.m. dated [DATE]. Problem area requires active range of motion to bilateral lower extremity 6 days per week dated [DATE]. Long term goal to maintain lower extremity strength to reduce risk of decline to perform sit to stand dated [DATE]. Approach for bilateral lower extremity using 2 to 3 pound cuff weights for 10 to 15 reps x 2 to 3 sets once a day during 7 a.m. to 3 p.m. dated [DATE]. Review of the minimum data set (MDS) dated [DATE] section C revealed the resident had a brief interview for mental status score (BIMS) of 15 meaning intact cognition. Review of the restorative nursing nursing category report from [DATE] to [DATE] revealed Resident #26 received one therapy session on [DATE] for range of motion and none for transfers. For the dates of [DATE] to [DATE] the resident received two therapy sessions, one on [DATE] for range of motion and transfer. One session on [DATE] for range of motion. During an interview with the Director of Rehabilitation (DOR) on [DATE] at 9:41 a.m. she stated the resident was on the restorative program for a few things and that they started using the care plans in the computer. Therapy adds the restorative nursing program to residents and the restorative nursing aide prints it out and completes the tasks as required. 2) During an interview with Resident #49 on [DATE] 9:20 a.m. she stated she is not getting restorative therapy on her back, shoulders and walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 6 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #49's admission documentation revealed the resident was admitted on [DATE] with a readmit date on [DATE] and diagnoses of low back pain, intervertebral disc disorders with radiculopathy, lumbar region. Review of physician orders revealed on [DATE] the resident was discontinued from skilled occupational therapy services to restorative nursing program. On [DATE] the resident was discontinued from the occupational therapy services to restorative nursing program. Review of the MDS dated [DATE] revealed in section C. a BIMS score of 14 meaning cognitively intact. Review of the care plan dated [DATE] for problem area ADL/Restorative Nursing program required resident do active range of motion to back and bilateral shoulders 6 days per week. Long term goal to maintain current level of function. Approach date [DATE] the resident will complete back and shoulder stretches for pain management x 20 reps once a day from 7 a.m. to 3 p.m. Problem start date of [DATE] for limited ability to dress/undress self. Long term goal to maintain ability to complete all ADL's and functional mobility with wheel chair at current level of function. Approach date of [DATE] to complete all ADL's with minimal assist, including transfers. Review of Resident #49's restorative nursing program dated [DATE] to [DATE] revealed the resident received therapy on [DATE] for range of motion. Review of Resident #49's restorative nursing program dated [DATE] to [DATE] revealed the resident received therapy on [DATE] and [DATE] for range of motion. During an interview on [DATE] at 9:40 a.m. with the Director of Rehab she stated the resident doesn't like to participate in therapy. She starts and stops and says its pointless but she has restorative nursing program for her ADL's, transfers and shoulders. 3) During an interview with Resident #64 on [DATE] at 11:26 a.m. she stated she is declining in her walking abilities and used to walk 325 feet but has not been getting restorative nursing and is wanting to get restorative nursing again since she can not walk like she used too. Resident #64 stated she is going to the bathroom on her own since staff take so long to assist her. During an interview on [DATE] at 9:00 a.m. Resident #64 stated she has not had restorative care due to the aide being pulled to work on the floor as a CNA. During an interview on [DATE] at 11:00 a.m. the resident stated she had not been to restorative but maybe 3 times and used to walk up to 325 feet and feels like she is loosing her abilities without therapy. During an interview on [DATE] at 11:25 a.m. Resident #64 stated she is hoping to regain therapy so she won't lose her abilities. Resident #64 confirmed she had restorative therapy maybe 3 times in a month. During an interview on [DATE] at 9:11 a.m. with the DOR, she stated therapy has been tasked with entering the restorative program in the computer and there will be no order for restorative just the order to discontinue therapy and move to restorative nursing program. The DOR stated Resident #64 is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 7 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 currently on active range of motion for upper body and was on lower body but that expired. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed Resident #64 was admitted on [DATE] with a readmit on [DATE] and diagnosis of rheumatoid arthritis and artificial knee. Residents Affected - Some Review of the physician order dated [DATE] revealed to discontinue skilled physical therapy and establish restorative nursing program. Review of the MDS dated [DATE], revealed in section C a BIMS score of 15, cognitively intact. Review of the care plan dated [DATE] revealed a problem area for active range of motion to bilateral upper extremities 6 days per week. Goal to increase strength for mobility an transfers. Approach date of [DATE] for bilateral upper extremity (bue) using one pound dowel and yellow theraband, all planes 3 sets of 10 reps as tolerated. [DATE] ADL resident requires active range of motion bilateral upper 6 days per week. resident will increase strength for mobility and transfers. bue using 1 lb dowel and yellow theraband, all planes 3 sets of 10 reps. Review of the restorative nursing report dated [DATE] to [DATE] revealed Resident #64 received restorative nursing on [DATE] for walking. Review of restorative nursing from [DATE] to [DATE] revealed Resident #64 received restorative nursing on [DATE] for range of motion. 4) During an interview with Resident #84 on [DATE] at 9:30 a.m. she stated she has not received restorative therapy and she needs help with all her extremities. During an interview with the DOR on [DATE] at 9:33 a.m. she stated the resident was on a functional maintenance program from January through March then she moved to the restorative nursing program through [DATE]th for bilateral upper extremities. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of multiple sclerosis. Review of the MDS dated [DATE] revealed a BIMS score of 15 for cognitively intact. Review of the care plan revealed a problem area on [DATE] for range of motion to bilateral upper extremity. Long term goal to decrease contracture to bilateral upper extremity. Approach date of [DATE] for bilateral upper passive range of motion, all planes as tolerated. Wear bilateral elbow splints daily, 4 to 6 hours as tolerated with skin check pre and post wear, once a day from 7 a.m. to 3 p.m. Problem start date of [DATE] for limited range of motion to bilateral elbows. Long term goal to maintain passive range of motion bilateral upper extremities, all planes to be able to assist with ADL's and use of joystick when in chair. Approach dated [DATE] to wear bilateral elbow splints daily as tolerated. Once a day from 7 a.m. to 3 p.m. Problem area dated [DATE] for limited range of motion to bilateral upper extremity. Long term goal to receive passive range of motion to bilateral upper extremity, daily to maintain range of motion to be able to assist with ADL's and use of joystick when in chair. Approach date of [DATE] for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 8 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some passive range of motion to bilateral upper extremities, all planes as tolerated. Once a day from 7 a.m. to 3 p.m. Review of the restorative nursing report dated [DATE] to [DATE] revealed the resident received therapy on [DATE] and [DATE] for range of motion and splint or brace assistance. Review of Resident #84's restorative nursing program dated [DATE] to [DATE] revealed the resident received therapy on [DATE] and [DATE] for range of motion. During an interview on [DATE] at 2:30 p.m. with Staff member O, CNA she stated she gets the census daily for restorative therapy and has 26 residents that need restorative therapy daily. She stated in the last month she has worked at least six days on the floor as a CNA. She stated, I can not keep up with restorative when I am working on the floor. Staff member O, stated she completes morning daily weights on residents that takes until around 10:30 a.m. then she will get a few residents to do restorative nursing and around 11 a.m. she gets residents ready for lunch then charts. Staff member O, stated, On a day when I work restorative I work 40 minutes before noon and after lunch about 3 hours a day as restorative aide. We used to have another restorative aide but now I am the only one and I work the floor as a CNA and next week I start monthly weights. I do not have enough help to do the restorative position. Staff member O, confirmed she did not have an effective restorative program after looking at the amount of therapy the residents have received since [DATE]st. Staff member O confirmed the unit manager is over the restorative program. During an interview with Staff member D, UM on [DATE] at 4:44 p.m. she confirmed the restorative nursing Residents #26, #49, #64 and #84 should be getting restorative nursing five to six days a week and they are not at this time. Staff member D stated she just acquired this position recently and was not aware the residents were not getting restorative therapy. During an interview with the Director of Nursing (DON) on [DATE] at 4:34 p.m. she confirmed that residents scheduled for restorative therapy should be getting therapy as directed. Review of the policy restorative nursing services revised [DATE], one page revealed: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. 2. residents may be started on restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the residents plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 9 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two residents (#86 and #26) were provided the correct size brief and incontinence care in order to provide comfort and maintain skin integrity of 3 residents sampled. Findings Included: 1) An interview with Resident #26 on 4/19/21 at 11:30 a.m. revealed the resident preferred the green briefs but stated they give him the yellow briefs which are too tight and hurt his (testicles). An interview with Resident #26 on 4/20/21 at 9:53 a.m. revealed the resident was showered yesterday and has been wearing the yellow briefs. Resident #26 stated he needs the green ones as the yellow ones are too tight for him and hurt. He stated when he urinates in the brief it gets tighter and starts hurting more but the green ones give him room and did not hurt. During an interview with Resident #26 on 4/21/21 at 9:35 a.m. he stated the yellow brief is rubbing him raw and it makes his testicles hurt. He confirmed he was last changed at 4:30 a.m. and the CNA will usually come in around 10:00 a.m. or 10:30 a.m. to change him again. He stated they never check on him every 2 hours. The resident stated he was never measured for a brief size and pulled the covers to reveal the yellow brief he was wearing and said look how tight it is. The resident stated that everyday the yellow one gets tight and hurts especially after he urinates. The resident stated he saw his aide today at 7:30 a.m. when she came in to separate towels and had not seen her since. The resident stated he told the unit manager that he needed the green briefs and she told him in the last two days that the order did not come in. The resident stated that he is not sure when he has to go to the bathroom all the time and if he was continent he would not be here! Resident #26 was admitted on [DATE] diagnoses of edema, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms and obstructive and reflux uropathy. Review of the Minimum data set (MDS) section C. resident brief interview for mental status (BIMS) dated 1/20/21 revealed a score of 15, (Cognitively intact). Review of section G, functional status revealed section I. toilet use as extensive assistance and one person physical assist. Review of the ADL care plan revealed the resident needing assistance with activities of daily living due to impaired mobility related to current medical condition BPH. Review of the care card revealed the resident continent using a brief size of extra large. 2) During an interview with Resident #86 on 4/21/21 at 9:28 a.m. the resident stated she personally gets changed and uses at least 3 to 4 green colored briefs a day. The resident said she last wore green briefs 2 days ago and that the facility was always running out of green briefs. Resident #86 stated she has not been measured her for briefs and said she gets a rash from sitting in the chair and said the green brief holds the stool but the yellow one is not as secure and will leak out. During an interview with Staff member K, CNA on 4/21/21 at 10: 00 a.m. she stated the resident normally wears a green brief and when they run out of green briefs they wear the yellow ones which are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 10 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smaller. The resident has been out of the green briefs every other day. Staff member K, stated they have a care card in the closet on the door and reviewed the care card which did not reveal a color of the brief. During an interview with the resident on 4/22/21 at 11:05 a.m. she stated yesterday with her yellow brief she urinated all over herself and her bed. She stated the green briefs on her are a little bulky but they hold the amount of urine she usually puts out. Resident #86 stated she felt lousy when she felt the urine going down her leg and up her back making her bottom burn and felt she should not have to experience that when the green briefs keep the urine contained. Review of the activities of daily living (ADL) the weaknesses described the resident as dependent for all aspects of care. Review of the 'care card' revealed the resident was incontinent. Review of the BIMS dated 3/16/21 revealed a BIMS score of 13, (Cognitively intact) . Review of MDS section H. for bowel and bladder revealed the resident was always incontinent. During an interview with Staff member M, CNA on 4/22/21 at 10:13 a.m. she stated if the resident wants a green brief they can have one. The staff would need to get them from central supply since they are not kept in the clean linen closet. Review of the brief supply audit completed on 4/22/21 revealed 15 green briefs on hand and stored in central supply with 20 cases of green briefs coming in on 4/22/21 shipment. The audit revealed the yellow briefs in the building included 3 cases plus 28 extra briefs and a shipment of 22 cases coming on 4/22/21. During an interview on 4/21/21 at 11:15 a.m. with the Director of Nursing (DON) she stated she had no idea that they were low on green briefs (XXL) or that residents were not getting the green briefs if they asked for them. The DON stated the company came in and measured residents to determine fit but the resident is allowed to get the green if they feel they need it. During an interview on 4/22/21 at 10:25 a.m. with the Nursing Home Administrator (NHA) she stated the briefs were ordered and she was not aware the briefs were not made available to the staff. The NHA stated she did not know the staff were putting the green briefs in the medication room or in central supply and not the clean linen closet where the other briefs were kept. Review of the policy and procedure for activities of daily living (ADL's), revised 2018, two pages revealed: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good personal hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. elimination (toileting) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 11 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure respiratory equipment was stored in a sanitary manner and had a physician order for the use of a Continuous Positive Airway Pressure (CPAP) machine for one (#265) out of two residents sampled for respiratory care. Residents Affected - Few Findings included: Resident #265 was admitted on [DATE]. The Face Sheet included a diagnosis of Obstructive sleep apnea. The admission Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status score of 15 out of 15, signifying that Resident #265 was cognitively intact. Section O: Special Treatments, Procedures, and Programs of the MDS did not identify the resident utilized a non-invasive mechanical ventilator while not a resident or while a resident. On 4/19/21 at 11:33 a.m., while interviewing Resident #265 as she sat in a wheelchair in front of her bedside dresser, a CPAP machine was observed sitting on the dresser. When asked how staff stored the mask she stated they lay it on her over-the-bed table and she tries to throw it onto the dresser. The resident reported the other day (unknown) she found the mask on the floor and that staff had not cleaned it when it was found. A review of Resident #265's physician orders did not include an order for the use of a CPAP machine. On 4/21/21 at 3:49 p.m., Resident #265's CPAP machine was observed sitting on the bedside dresser and the nasal pillow mask was lying behind the machine on the dresser. On 4/21/21 at 3:54 p.m., an observation was conducted with the Director of Nursing (DON) of Resident #265's CPAP machine. The nasal pillow mask was on the dresser behind the CPAP machine. Resident #265 stated her son had brought it from home and the staff were so nice to supply the distilled water. When asked if the resident should have a physician order for the CPAP, she stated that yes the resident should have an order for it. The DON and this writer went to the Unit Manager (UM) office and the DON directed the Staff Member H (UM) to look for an order for the CPAP then she left the office. Staff H confirmed that the resident did not have an order for the use of the CPAP. The DON returned to the office and informed the UM that the family had brought it (CPAP) in while the UM confirmed that the facility did need an order for the CPAP. During a review of the physician orders, on 4/21/21 at 4:17 p.m., a physician verbal order was identified for Resident #265's CPAP use at bedtime. The order was created on 4/21/21 at 4:15 p.m. by Staff Member H, Unit Manager. The facility also received an order, to start on 4/21/21, to cleanse CPAP tubing with mild soap and warm water every Saturday. Resident #265's care plan identified, created on 4/13/21, that the resident had a potential for difficulty breathing related to sleep apnea. The approaches for the resident breathing difficulty instructed licensed nursing staff to administer/monitor effectiveness of the following treatments: - Elevate head of bed (HOB) at least 45 degrees as needed (prn); - Encourage coughing/deep breathing prn; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 12 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 - Bipap (C-pap). Level of Harm - Minimal harm or potential for actual harm A request was made for a policy regarding the storage of Respiratory Equipment, the facility provided a policy, 2001 Med-Pass, Inc. (revised October 2018), Cleaning and Disinfection of Resident-Care Items and Equipment. The policy statement indicated that Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers of Disease Control and Prevention (CDC) recommendations for disinfection. The policy identified that equipment that came in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment) were considered semi-critical items and should be free from all microorganisms, allowing for a small number of bacterial spores. The policy identified that semi-critical items will be sterilized/disinfected in a central processing location and stored appropriately until use and that the items would be labeled with date and time it was affixed to the equipment. The policy did not address the aspect of the daily storage of residents respiratory equipment. Residents Affected - Few According to sleep association.org (https://www.sleepassociation.org/sleep-apnea/cpap-treatment/how-to-clean-your-cpap/) to protect the user and the machine it is important to care for a CPAP machine in a proper manner. The website described that during use the exhaled air goes back into the mask, tubing, and machine contains moisture and that microorganisms thrive on moisture and particulate manner. The association recommended to rinsing the equipment with water for one minute then make sure standing water can drip out of the tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 13 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and four errors were identified for three (#75, #81, and #28) of five residents observed. These errors constituted a 16% medication error rate. Residents Affected - Some Findings included: The policy titled Administering Medications, 2001 Med-Pass Inc. (Revised April 2019), acknowledged that Medications are administered in a safe and timely manner, and as prescribed. The policy identified the following Interpretation and Implementations: - 3. Medications are administered in accordance with prescriber orders, including any required time frame.; - 6. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - 8. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. On 4/20/21 at 8:25 a.m., an observation of medication administration with Staff Member A, Registered Nurse (RN), was conducted with Resident #75. Staff Member A was observed administering the following medications: -- Pure Aide 0.4/0.3% Lubricant Eye drops - Biofreeze topical gel - Mucus Relief (Guiafenesin) 400 milligram (mg) tablet - Multi Vitamin with minerals tablet - Eliquis 5 mg tablet - Ropinirole 0.25 mg tablet - Primidone 50 mg tablet A review of the Medication Administration Record (MAR) for Resident #75 revealed the following medications were not administered as physician ordered: - Mucinex (Guaifenesin) Extended Relief 12 hour (hr) 600 mg tablet orally every 12 hours. - Calcium with Vitamin D (calcium carbonate - vitamin D3) 600 mg orally daily. During the observation, Staff A notified Resident #75 that she did not have the Calcium with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 14 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Vitamin D but would hunt it down. The MAR for the resident indicated on 4/20/21 at 8:43 a.m., Staff A noted that the Calcium with Vitamin D was unavailable for administration. 2. On 4/20/21 at 8:55 a.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN), was conducted with Resident #81. Staff Member I was observed administering the following medications: - Carbamazepine 200 milligram (mg) tablet - Vitamin B-12 1000 microgram (mcg) tablet - Senna Plus 8.6/50 mg tablet - Topamaz 50 mg tablet - 2 Vitamin C 250 mg tablets - Fluticasone Propionate nasal spray A review of the Medication Administration Record (MAR) for Resident #81 revealed the following medication was not administered as physician ordered: - Geri-kot (sennosides - Over the Counter (OTC)) 8.6 mg tablet: Give one tablet by mouth twice daily. Dx: Constipation. 3. On 4/20/21 at 8:48 a.m., an observation of medication administration with Staff Member I, Licensed Practical Nurse (LPN) was conducted with Resident #28. The staff member administered oral medications without any concerns. After an observation of another resident's (#81) administration the electronic Medication Administration Record (MAR) indicated that Resident #28's profile was colored red. When asked what the red meant, Staff I asked this writer if they knew anything about the system, acknowledged that the resident had a late medication, and stated I must have missed it. The following medication administration was observed at 9:00 a.m. for Resident #28: - Basaglar KwikPen U-100 Insulin glargine) Insulin pen; 100 units/milliliter (mL); 34 units subcutaneous. The observation identified that Staff I dialed the KwikPen to 34 units, entered the resident room, donned gloves, stood next to the resident. The staff member complied with stepping outside the resident room with this writer prior to injecting 34 units of insulin. While standing next to the medication cart, Staff I was asked if she had primed the KwikPen, she admitted that she had not and that she did usually prime the pen. The staff member wasted 34 units of Basaglar insulin, retrieved another fine needle from another floor nurse, primed the pen with 2 units, dialed 34 units of insulin, and then administered it to the resident. A review of Resident #28's MAR indicated Staff I had documented, on 4/20/21 at 9:14 a.m., Late Administration: Charted Late. Comment: 0. The MAR did not indicate that the physician was notified that the residents Basaglar insulin was administered one and one-half hours later than scheduled and after the resident had eaten breakfast. According to the manufacturer literature, Basaglar KwikPen should be prime before each injection. The literature identified, priming means removing the air from the Needle and Cartridge that may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 15 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some collect during normal use. It is important to prime your pen before each injection so that it will work correctly and if you do not prime before each injection, you may get too much or too little insulin. The instructions for the Basaglar KwikPen indicated to prime you pen, turn the dose knob to select 2 units, hold pen with needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, and while holding you pen with needle up, push the dose knob until it stops, the user should see insulin at the tip of the needle. This information was located at: https://uspl.lilly.com/basaglar/basaglar.html#ug0. At 4/22/21 at 11:26 am., an interview was conducted with the Consultant Pharmacist. She confirmed that medications should be available to be administered including over the counters and that that staff should verify that the correct medication is dispensed and administered. She confirmed that the Basaglar Kwikpen should be primed prior to each use and that Basaglar can be given anytime of the day as long as staff reached out to the physician. At 12:33 p.m. on 4/22/21, the Director of Nursing was interviewed regarding the Medication Administration observations. When asked if insulin pens should be primed prior to use, she stated she believed so but would like a chance to confirm. The Director of Nursing did not offer any further information regarding this concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 16 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review the facility failed to store medications with an appropriate pharmacy label, failed to dispose of expired medications, failed to ensure two of four treatment carts and one of six medication carts were inaccessible to residents and visitors. Findings included: At 9:00 a.m. on 4/20/21 during an observation of medication administration for Resident #28 Staff Member I, Licensed Practical Nurse (LPN), was observed removing a Basaglar insulin Kwikpen from a clear bag labeled for Basaglar, inside the bag was also a Novolog insulin FlexPen. The Novolog FlexPen was labeled with the open date of 3/9/21 and indicated it should be disposed of 28 days after opening, April 6, 2021. At 9:14 a.m., Staff I confirmed that the Novolog FlexPen was stored with the Basaglar Kwikpen and since it was expired it should be disposed of. An observation occurred on 4/20/21 at 7:20 a.m., of an unlocked treatment cart outside of room [ROOM NUMBER]. Two staff nurses were giving and receiving report at the other end of the hall. Observed inside of the cart were physician prescribed topical lotions, creams and powders, and sterile dressing packages. At 7:25 a.m., the two nurses walked by and confirmed the cart was open, and one of them locked the cart. On 4/20/21 at 7:31 a.m., an observation was made of a treatment cart outside of room [ROOM NUMBER]. Multiple staff were sitting at the nursing station and a Certified Nursing Assistant (CNA) entered a nearby room then shut the door. At 7:37 a.m., the cart remained unlocked as the CNA left the area. At 7:42 a.m., Staff Member J, Licensed Practical Nurse (LPN) confirmed the treatment cart should not be unlocked. The staff member confirmed it was her cart however she had just arrived and was unaware it was unlocked. At 4:24 p.m. on 4/20/21, an observation was made of a medication cart on the first floor, parked in the corner outside of room [ROOM NUMBER], unlocked and unattended. Staff Member E, LPN, was observed at other end of the hallway administering medications. At 4:28 p.m., the Nursing Home Administrator (NHA) and Staff Member D, Unit Manager (UM), came out into the hallway from behind the nursing station. The UM explained that Staff Member E was working both the unattended unlocked cart and the cart that he was using at the end of the hallway. When asked if staff should keep carts unlocked and accessible to others due to working both carts, the NHA stated, absolutely not and the UM stated that the cart should be locked. When Staff E was approached by this writer and the UM, he stated he was unaware the cart was unlocked and hadn't been in the cart yet. The policy titled Storage of Medications, 2001 Med-Pass Inc. (Revised April 2007), indicated that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The Interpretation and Implementation portion of the policy indicated the following: - 1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 17 of 18 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm - 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - 4. The facility shall not use discontinued, outdated, or deteriorated drugs of biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Residents Affected - Few - 5. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. - 6. Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications. - 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. - 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 18 of 18