Health inspection·May 4, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 one (Resident #7) of two residents sampled for the self-administration of medications was assessed and determined to be clinically appropriate and safe to administer medications. Residents Affected - Few Findings included: An observation was conducted at 10:04 a.m. on 5/4/23 of two medication cups on the over-bed table of Resident #7. There were no residents in the room during the observation. Staff C, Licensed Practical Nurse/LPN observed and confirmed on 5/4/23 at 10:18 a.m., the presence of the two medication cups on Resident #7's over-bed table. Staff C stated the resident was competent and able to take meds by self. Staff C identified one of the tablets as Labetalol, a beta-blocker, and the other was a vitamin. Staff C declined to disclose the name of vitamin. Staff C stated the medications were given at breakfast. He said the resident was at Dialysis and had been on Dialysis for so long, they knew which medications could be taken before Dialysis and which ones should not be taken. A review of the facesheet for Resident #7 revealed the resident was admitted on [DATE] with diagnoses not limited to end stage renal disease, unspecified tremor and atherosclerotic heard disease of native coronary artery with unspecified angina pectoris. The 5-day Minimum Data Set (MDS), identified the resident's Brief Interview of Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. The review of Resident #7's physician orders did not reveal an order that would allow the resident to self-administer medications. The physician order list included an order, dated 4/21/23 that instructed staff to Do not hold medications for dialysis. A review of progress notes and documents did not include an assessment for Resident #7's ability to self-administer medications. Resident #7's Medication Administration Record (MAR) was requested but not received. On 5/4/23 at 3:37 p.m., the Director of Nursing (DON) stated the doctors sign off on the self-administration forms and it was not included in the physician orders but uploaded in the documents tab under progress notes. The DON stated Resident #7 could probably self-administer but did not know about an evaluation. She reviewed the uploaded progress notes, (physician notes) and confirmed neither note included a self-administration evaluation. The DON stated staff were to stay with the residents to ensure the residents took their medications. The policy - Self-Administration of Medications, identified Residents have the right to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 106079 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 05/04/2023 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)