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 Page 1 of 6 106079 106079 05/04/2023 Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The interpretation and implementation included: - 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. - 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: -- b. Comprehension of the purpose an proper dosage and administration time for his or her medications; - 5. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. - 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe store is not possible in the resident's room, the medication of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 106079 Page 2 of 6 106079 05/04/2023 Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the controlled substances of one (Resident #8) of three residents sampled was accurately reconciled after the administration of the medication. Findings included: On 5/4/23 at 10:22 a.m., Staff C, Licensed Practical Nurse (LPN) reported being unaware of any discrepancy regarding the accounting of controlled substances. The staff member stated if there was a discrepancy in the accounting, if someone did not add or subtract correctly, and if unable to rectify it, the supervisor was notified. A review of Resident #8's controlled substances on 5/4/23 at 12:40 p.m. was conducted with Staff C. The Individual Resident's Controlled Substance Record identified 30 tablets of 0.5 milligram (mg) of Lorazepam was delivered on 4/30/23. The record indicated 24 tablets should be remaining. The observation with Staff C revealed 25 tablets remained on the blister card. Staff C pointed to the count above and said, doesn't that look like a 5?, this is what we talked about earlier. Staff C confirmed the count on the form should match the amount of tablets that remained on the card. A review of Resident #8's facesheet indicated the resident was admitted on [DATE] and the diagnoses included generalized anxiety disorder. The residents' May Medication Administration Record (MAR) indicated a physician order for Lorazepam 0.5 mg - Give 1 tab by mouth every 2 hours as needed for anxiety. The review of Resident #8's Controlled Substance Record for Lorazepam indicated that the resident received one tablet on 5/1/23 at 10:00 p.m., one tablet at 2:30 p.m on 5/2/23, one tablet at 9:00 p.m. on 5/2/2023, one tablet at 7:00 p.m. on 5/3/2023, and one tablet at 9:00 a.m. on 5/4/23, a total of 5 tablets which at the time of the observation with Staff C left the remaining tablets, 25 (30-5 = 25). A review of Resident #8's MAR indicated that the resident was not administered Lorazepam at anytime on 5/1/23. The policy - Controlled Substances, identified that The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The interpretation and implementation indicated that the record should contain #4 , L: signature of nurse administering medication and 8: Licensed Nurses are to count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty count together. They must document and report any discrepancies to the Director of Nursing Services/designee at the time observed. 106079 Page 3 of 6 106079 05/04/2023 Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655

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, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-one medication administration opportunities were observed and three errors were identified for one (Resident #6) of one residents observed. These errors constituted a 14.28% medication error rate. Residents Affected - Few Findings included: On 5/4/23 at 9:44 a.m., an observation of medication administration with Staff C, Licensed Practical Nurse (LPN) was conducted with Resident #6. The staff member dispensed the following medications: - Aspirin Enteric-coated 81 milligram (mg) tablet - Magnesium Oxide 400 mg tablet (staff member dispensed one tablet from a bottle in another medication cart) - Vitamin C 250 mg - 2 tablets - Vitamin B12 100 microgram (mcg) tablet The staff member confirmed that 5 tablets had been dispensed at this time. - Topiramate 100 mg tablet - Pantoprazole 40 mg tablet - Metolazone 2.5 mg tablet - Multi-Vitamin tablet - Vitamin E 90 mg (200 international unit (iu)) tablet - Lidocaine 4% topical patch - Carbamazepine 200 mg - 1.5 tablets - Potassium Extended Release (ER) 20 milliequivalent - 2 tablets - Cranberry 450 mg tablet - Docusate Sodium 100 mg softgel - Atarax 50 mg tablet - Tamsulosin 0.4 mg capsule - Zonisamide 100 mg - 2 capsules 106079 Page 4 of 6 106079 05/04/2023 Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655

F 0759 - Losartan 50 mg tablet Level of Harm - Minimal harm or potential for actual harm - Furosemide 40 mg tablet - Methocarbamol 500 mg tablet Residents Affected - Few - Carvedilol 12.5 mg tablet Staff C said Resident #6's aspirin tablet was due at 8:00 a.m. He reviewed the dispensed medications to ensure all were noted. He entered the resident's room and placed the medication cup on the over-the-bed table. Staff C applied the Lidocaine patch to the resident's left shoulder. The resident asked for applesauce to take medications. Staff C left the room, leaving the medications on the table. The observation continued after returning to the room. The resident had dumped the tablets/capsules onto a blanket. Staff C watched the resident take the medications. A review of Resident #6's Medication Administration Record (MAR) revealed the following physician orders that were not followed during the observation: - Magnesium Oxide 500 mg - Give 2 tablets (1000 mg) by mouth daily, diagnosis (dx) age-related deficiency. - Vitamin E 180 mg softgel - Give 1 capsule by mouth by daily, dx: age-related deficiency. - Aspirin 81 mg chewable tablet - oral once daily (1) time a day. On 5/4/23 at 3:37 p.m., the Director of Nursing (DON) stated the expectation was to follow physician orders. A policy regarding the Administration of Medications was requested but not received. 106079 Page 5 of 6 106079 05/04/2023 Trinity Regional Rehab Center 2144 Welbilt Blvd Trinity, FL 34655

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, review of the facility policy, and interviews, the facility failed to ensure medications were not accessible to residents, visitors, and/or unauthorized staff on one (Cart 2) of two medications carts on the second floor. Findings included: On 5/4/23 at 9:40 a.m., an observation was made of a nurse leaving a medication cart parked outside of room [ROOM NUMBER] and entering a nearby resident room. A continued observation indicated that the medication cart was unlocked while unattended, a medication cup with medications in it and 2 bottles of over-the-counter (OTC) medications were sitting on top of the cart. At the same time of the observation, another staff member, Staff Member B (Registered Nurse/RN), walked to cart and locked it. Staff B confirmed that the medication was unlocked and unattended. Staff Member C (Licensed Practical Nurse/LPN) confirmed the presence of the bottles of Ibuprofen and Docusate Sodium on top of the medication cart. Staff C confirmed that bottles did contain medications. The staff member stated, if you want to call them meds, their stool softener and Ibuprofen. During the task of medication administration, Staff C dispensed a tablet of low-dose aspirin into a medication cup then placed the med cup behind the carts' laptop, don't touch that and walked to another medication cart parked further away from the nursing station. The staff member returned with a tablet and continued to dispense Resident #6's medications. The policy - Storage of Medications, indicated that The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The interpretation and implementation of the policy identified that: 1. Drugs and biologicals used in the facilty are stored in locked compartments under proper temperature, light, and humidity controls. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs an d biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. 106079 Page 6 of 6