Health inspection·November 21, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with the resident/responsible party. Once completed, the grievance form is returned to social services. The SSD stated, we like to get them back in three to five days. The SSD stated most of the grievances get resolved, some are repeating. The SSD stated call light concerns seem to repeat, although she was not sure as tracking of grievances is by department, not by issue. During an interview on 11/18/24 at 12:55 p.m. the Nursing Home Administrator (NHA) stated the follow through on grievances should be to have them wrapped up in approximately 72 hours. The NHA stated she did not have any information regarding the grievances. The NHA stated the SSD does complete a trending of grievances and that she does not. During an interview on 11/19/2024 at 10:30 a.m. with the Resident Council President. The Resident Council President stated the concerns regarding call lights continue to be an ongoing issue without resolution. Review of the facility's policy and procedure titled, Grievance/Complaint, Filing, with a revision date of August 2022, revealed: Policy: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy interpretation and implementation: 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, staff to property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues but will be responded to in writing, including a rationale for the response. 10. The grievance officer, administrator and staff will take immediate action to prevent further potential violation of resident rights while the alleged violation is being investigated. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct and identify problems. a. The administrator, or his/her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation can be provided to the resident upon request and a copy will be filed in the grievance binder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 2 of 20 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 11/21/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation was conducted on 11/18/24 at 2:52 p.m. of Resident #42 in bed. The resident had a dressing on each foot that was not dated. Residents Affected - Some Review of the admission Record showed Resident #42 was admitted on [DATE] with diagnoses including non-pressure chronic ulcer of right heel and midfoot with unspecified severity, non-pressure chronic ulcer of other part of right foot with unspecified severity, peripheral vascular disease (PVD), and acquired absence of other left toes. Review of Resident #42's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/24, revealed under Section C - Cognitive Patterns, showed the resident had a BIMS score of 14, indicating he was cognitively intact. Review of Resident #42's Skin Only Evaluation, dated 11/18/24, showed he had current skin issues on the right toe, right dorsal foot, left heel, and right heel. Review of Resident #42's care plan showed a focus area of skin disruption related to a left heel PVD ulcer and right heel PVD ulcer (with gangrene). Interventions included treatment per orders and avoid friction and shearing when doing care by lifting resident utilizing draw/turn sheets. Review of Resident #42's November 2024 physician orders showed the following: - Cleanse wound to left heel with wound cleanser, pat dry. Apply silver alginate, cover with abd (abdominal) and wrap with kerlix. Every night shift and PRN (as needed). Dated 9/25/24. - Cleanse wound to right heel with wound cleanser, pat dry. Apply silver alginate, cover with abd and wrap with kerlix. Every night shift and PRN. Dated 11/7/24. Review of Resident #42's Treatment Administration Record (TAR) showed the wound orders were signed off as completed on 11/18 and 11/19/24. An observation was conducted on 11/19/24 at 3:00 p.m. of Resident #42. The dressings on each heal were observed unchanged with no date. The right heel dressing was soiled with a quarter sized area of serosanguineous drainage. An additional observation of Resident #42 conducted on 11/20/24 at 9:54 a.m. revealed the two dressings remained in place unchanged and undated. The area of serosanguineous draining soiling the right heel dressing had increased to half-dollar sized. An interview was conducted on 11/20/24 at 2:05 p.m. with Staff D, LPN. She stated wound care was provided daily by the resident's assigned nurse on the night shift and weekly the wound nurse practitioner does a wound evaluation. When asked about Resident #42's dressing not being dated for the past 3 days, she stated it was done by the night nurse. She then added that she noticed another one of her residents also had an undated dressing. An observation on 11/20/24 at 3:07 p.m. revealed Resident #42's dressing remained unchanged and undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 3 of 20 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 11/21/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted on 11/21/24 at 9:30 a.m. with Resident #42. He said at 1:30 a.m. on 11/21/24 his dressing was changed. He was not happy it was done in the middle of the night. He said his dressing is not changed daily. 3. During an interview on 11/18/24 at 11:31 a.m. Resident #263 stated concern regarding the treatment of her wounds not being completed. Resident #263 continued to state on Friday 11/15/24 her left heel started to bleed, and all the nurse did was wrap a towel around the heel and nothing has been done since. Resident #263 was observed lying in bed. The resident's left foot was observed in a Podus type boot with a towel under the heel and a bandage covering the ankle and heel, dated 11/14/24. The resident's toes were exposed. The big toe had what appeared to be dried blood on the outer tip of the toe and nail. On 11/19/24 at 10:00 a.m., Resident #263 was observed and interviewed while lying in bed. The resident's left foot was observed in a Podus type boot with towel under the heel and a bandage covering the ankle and heel, dated 11/14/24. The resident stated no one had changed the bandages. Review of the admission Record revealed Resident #263 was admitted to the facility on [DATE], with diagnoses to include osteomyelitis to left ankle and foot, type 2 diabetes mellitus with foot ulcer, pressure ulcer of left buttock, and other co-morbidities. Review of Resident #263's MDS, Section C - Cognitive Pattern, dated 11/20/2024, revealed a BIMS score of 15/15, which meant the resident was cognitively intact. Review of Resident #263's November 2024 active Order Summary Report showed the following orders: - Cleanse left heel with normal saline, apply Santyl ointment, cover with ABD pad, and wrap in kerlix, change Monday, Wednesday, and Friday evening shift for wound care - dated to start 11/15/24 and discontinued 11/17/24. - Cleanse left heel with normal saline apply Santyl ointment cover with ABD pad and wrap in kerlix, change Monday, Wednesday, and Friday night shift for wound care - dated to start 11/18/24 and discontinued 11/21/24. A review of the TAR for November 2024 for Resident #263 showed treatment for the left heel provided was on 11/15/24 and 11/18/24. 4. On 11/18/24 at 12:02 p.m. and 11/20/24 at 1:25 p.m., Resident #264 was observed in the resident's room. Resident #264's left arm had a dressing (4x4 gauze with transparent dressing covering) with no date. During an interview on 11/18/24 at 12:05 p.m. Resident #264 and a family member noted the dressing on resident's left forearm. The resident and family were unaware of what happened to require a dressing. The family representative stated, Since the bandage is not dated, I'm not sure when it happened. During an interview on 11/20/24 at 1:40 p.m., Staff D, LPN confirmed routinely caring for Resident #264. Staff D, LPN stated, she was not aware of the dressing on Resident #264's arm. Staff D, LPN reviewed the electronic record for Resident #264, including current orders, and no orders for treatment were found. Staff D, LPN entered the resident room and asked Resident #264 what happened and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 4 of 20 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 11/21/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Resident #264 stated no recollection. Staff D, LPN confirmed the dressing was on the resident's left forearm and was not dated and should have been. During an interview on 11/21/24 at 2:09 p.m. the Director of Nursing (DON) stated the dressing should be dated and the expectation is for the nurses to follow the physician orders. Residents Affected - Some Review of the facility's policy and procedure titled, Wound Care, with a revised date of October 2010, showed: Purpose: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify there is a physicians order for this procedure. 2. Review the residence care plan to assess for any special needs of the resident. a. Themselves for example, the resident may have PRN (as needed) orders for pain medication to be administered prior to wound care. 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etcetera., with alcohol pledge it before opening, as necessary. (Note: this may be performed at the treatment cart.) .Steps in the Procedure: .13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date and apply to dressing. Be certain all clean items are on clean field Documentation: The following information should be recorded in the resident's medical record: 1. Wound care provided. 2. The date and shift the wound care was provided. 3. The name and the title of the individual performing the wound care. (Photographic Evidence Obtained) Based on observation, interview, and record review, the facility failed to ensure four residents (#413, #42, #263, and #264) of four residents reviewed for wound care concerns received wound care treatment in accordance with professional standards of practice. Findings included: 1. An observation and interview was conducted with Resident #413 on 11/20/24 at 1:30 p.m. Resident #413 was observed sitting in a chair dressed in day clothes next to her bed. A gauze dressing was observed on her left lower leg with a date of 11/16. The resident stated, The dressing hasn't been changed in four days and it is supposed to be changed every other day. Every time I ask about it, the nurse tells me the next shift will do it. Review of Resident #413's admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses of congestive heart failure, and non-pressure chronic ulcer of left calf. Review of Resident #413's progress note - Brief Interview for Mental Status (BIMS) evaluation, dated 11/11/24, revealed a BIMS score of 15 indicating she is cognitively intact. Review of Resident #413's November 2024 active physician orders revealed an order with a start date of 11/09/24 for cleanse LT [left] lower posterior leg open area with nss [normal saline]; apply silver Alg [alginate], Abd [abdominal dressing] and wrap with a gauze change QOD [every other day] every night shift every other day for wound. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 11/20/24 at 3:10 p.m. She said the wound care practitioner comes to the facility once a week and usually rounds with the unit managers. If an order is changed or updated, sometimes the wound care practitioner will put it in that day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 5 of 20 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 11/21/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete An interview with the Wound Care Nurse Practitioner was conducted on 11/21/24 at 11:02 a.m. She stated she would not expect to see dressings not changed as ordered. She also stated she didn't see a date on Resident #413's dressing and would not expect a dressing that is supposed to be changed every other day to not be changed for five days. She went on to state since Resident #413's dressing was not changed, it was hard to get off and she had to moisten it. She said if the order needs to be changed in the system, she will put the order in, and sometimes she does have an issue with the dressings not being changed as ordered. Event ID: Facility ID: 106079 If continuation sheet Page 6 of 20 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 11/21/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement safety precautions for smoking supplies for one resident (#52) of one sampled resident for smoking. Findings included: On 11/18/2024 at 11:47 a.m. Resident #52 was observed in her room sitting in her wheelchair, with an electronic monitoring device on her right ankle and her purse next to her with cigarettes and a lighter. Resident #52 stated she was a smoker and is able to go smoke with the activity department at specific times of day. On 11/18/2024 at 4:12 p.m. Resident #52 was observed sitting in a wheelchair being escorted to the second-floor elevator. The resident had cigarettes and a lighter in her purse next to her in the wheelchair. Review of the admission Record revealed Resident #52 was admitted to the facility on [DATE]. Review of Resident #52's Minimum Data Set (MDS) assessment, dated 10/9/2024, Section C- Cognitive Pattern, revealed a Brief Interview for Mental Status (BIMS) score of 11/15, which meant the resident was moderately cognitively impaired. Review of Resident #52's smoking assessment, dated 9/29/2024, showed Resident #52 is not a smoker. Review of Resident #52's smoking assessment, dated 10/15/2024, showed Resident #52 has cognitive loss, smokes 1-2 cigarettes per day, not able to light own cigarette, resident needs supervision, resident needs facility to store lighter and cigarettes. Under the section of the IDTC (Inter Disciplinary Team Conference) Decision showed: Resident have [sic] fluctuations in her cognition throughout the day, safe to smoke with supervision and Smoking policy reviewed. Review of Resident #52's smoking assessment, dated 10/23/2024, showed Resident #52 does not have cognitive loss, smokes 1-2 cigarettes per day, is able to light own cigarette, resident needs supervision, resident needs facility to store lighter and cigarettes. Under the section of the IDTC (Inter Disciplinary Team Conference) Decision shows: Needs supervision, safe to smoke with supervision and Resident follows other residents outside to smoke. She needs supervision to get in and out of building safely. Review of Resident #52's care plan, dated 10/3/2024, showed a Focus Area: [Resident #52] has impaired cognition with memory problems related to BIMS = 11/15. - Smoking dated 10/14/2024 showed the resident is a smoker. The goal for Resident #52 showed, will smoke safely at designated area(s) through next review. The interventions included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. The resident requires SUPERVISION while smoking per facility practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 7 of 20 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 11/21/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 11/20/2024 at 1:38 p.m. Staff H, LPN confirmed caring for Resident #52 and stated Resident #52 is a smoker and goes out with supervision. Staff H, LPN continued to state usually if a resident is marked needing supervision, we (the staff) would hold the supplies (cigarettes and lighters) although Resident #52 holds all of her supplies. An interview was conducted with the Nursing Home Administrator (NHA) on 11/20/2024 at 4:22 p.m. The NHA reviewed Resident #52's smoking assessments from 9/29/2024, 10/15/2024 and 10/23/2024. The NHA confirmed the assessments showed the resident was in need of supervision. Review of the facility's policy titled, Smoking Policy - Residents, revised July 2017, showed: Policy Statement- This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation . 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: (a). Current level of tobacco consumption; (b). Method of tobacco consumption (traditional cigarettes; Electronic cigarettes; Pipe, etc.); (c). Desire to quit smoking, if a current smoker; and (d). Ability to smoke safely with or without supervision (per a completed safe smoking evaluation). 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident smoking privileges based on the safe smoking evaluation. 8. A residents ability to smoke safely will be reevaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, E cigarettes, pipes, tobacco, and other smoking articles in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited.14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etcetera, except when they are under direct supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 8 of 20 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 11/21/2024 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure a central line dressing was changed as ordered for one resident (#33) out of four residents sampled. Residents Affected - Few Findings included: On 11/19/24 at 10:46 a.m., an observation was made of Resident #33's peripherally inserted central catheter (PICC) dressing, dated 10/27/24. Resident #33 stated he was getting an intravenous antibiotic for an infection but could not state where the infection was. On 11/20/24 at 8:40 a.m. an observation was made of Resident #33's PICC dressing with a remnant of a sticker on the clear dressing. Resident #33 stated he did not know what happened to the dressing. On 11/20/24 at 10:45 a.m. an observation was made of Resident #33's PICC dressing with the same remnant of a sticker on the clear dressing, but a date of 11/20 written in a green marker with identified initials. A review of Resident #33's admission Record showed an initial admit date of 11/2/2021, with a readmission date of 10/10/2024. A review of the admission Record showed Resident #33 diagnoses not limited to encounter for orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis, other sites, and atherosclerosis of native arteries of extremities with gangrene right leg. A review of Resident #33's current physician orders showed orders for the following: - Vancomycin Hydrochloride (HCL) Intravenous solution reconstituted 1.25 grams, use 1.25 grams intravenously two times a day for osteomyelitis with a start date of 11/12/2024. - Change PICC line dressing on right upper arm (RUA) weekly on Sunday every day shift every Sunday with a start date of 10/20/2024. - Monitor PICC line site on RUA for s/s (signs and symptoms) of infection every shift with a start date of 10/13/2024. A review of Resident #33's Minimum Date Set, dated 10/29/24, Section O - Special Treatments, Procedures and Programs showed a check mark for Other H1. IV medications while a resident. On 11/20/24 at 11:05 a.m. an interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff L, LPN/UM stated she was the nurse wrote today's date in green onto Resident #33's PICC line dressing. Staff L, LPN/UM stated she saw the remnants of the sticker on the dressing, which prompted her to ask the resident if anyone had changed the dressing. Staff L, LPN/UM stated she asked the resident if his dressing was changed and she stated the resident stated to her something was done yesterday. Staff L, LPN/UM marked the dressing with the green marker for today's date. Staff L, LPN/UM stated PICC line dressings are changed within 24 hours of a new resident's arrival to the facility and then every seven days per physician orders and as needed for soiling or if the dressing should be loose. A review of the facility's policy and procedures titled, Central Venous Catheter Dressing Changes, revised January 2020, showed a purpose statement: The purpose of this procedure is to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 9 of 20 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 11/21/2024 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 0694 catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Level of Harm - Minimal harm or potential for actual harm Further review of the policy showed the following general guidelines: Residents Affected - Few 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. Explain to the resident that the dressing should not get wet. 2. Change dressing if any suspicion of contamination is suspected. 3. Catheter site care shall allow for the observation and evaluation of the catheter skin junction and surrounding tissue. 4. After original insertion the dressing will consist of gauze and semi permeable membrane dressing. This must be changed within 24 hours 5. Change transparent semi permeable membrane dressing at least every five to seven days and PRN (as needed) when wet soiled or not intact. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 10 of 20 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 11/21/2024 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 - Some 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** 2. An observation of Resident #59's room on 11/18/24 at 11:11 a.m., revealed 11 packets of peri-care ointment, 5 grams each, laid on top of a nightstand. An interview was conducted following the observation with Resident #59. Resident #59 stated he was unaware the ointments were left on the nightstand. Review of the admission Record showed Resident #59 was re-admitted to the facility on [DATE]. There were no medication self-administration assessments found in Resident #59's medical record. The Order Summary Report showed no orders for Resident #59 to self-administer his own medications. Based on observations, interviews, and policy review, the facility failed to ensure medication was stored appropriately in four resident rooms out of thirty-six resident rooms sampled, in three medication carts out of five facility medication carts, and one medication storage room out of two facility medication storage rooms. Findings included: 1. An observation and interview was conducted on 11/20/24 at 9:09 a.m. with Staff E, Licensed Practical Nurse (LPN). Upon approaching the medication cart in the 100 hall the nurse opened the top drawer. One medication cup that had medication crushed in apple sauce with a spoon in it and two medication cups with medication were observed in the top drawer. The nurse was observed removing a fourth medication cup filled with medication from the drawer. When asked what the cups of medication were for she said she was going to administer them to residents. She said she pulled them and did both residents in the room. She had no response when asked if it was ok to have medications pulled and sitting in the medication cups in the drawer. An audit of a first-floor medication cart was conducted on 11/20/24 at 10:48 a.m. with Staff E, LPN. The medication cart had six loose pills in the drawers of the cart. The top drawer contained an insulin pen with no resident label. The medication cart drawers were observed to contain tape, scissors, thermometer, blood pressure cuff, stethoscope, pulse oximeter, and pudding in the same compartments containing medication. The top drawer was observed to have dirt/debris in the corners and rust spots on the metal. The narcotic drawer contained 3 vaping cartridges, hearing aids, and an unlabeled, open bottle of nasal spray. The bottom of the medication cart, behind the drawer, contained several loose pills, debris, and a bubble pack of resident medication. Staff E, LPN said the insulin pen probably fell out of the bag it was in, and the prescription label came off. Staff E, LPN said she did not know other items could not be stored in the cart with medication. She said there had not been education on the medication carts with the exception possibly of orientation. She said loose pills were not supposed to be in the cart and if she saw them, she would have removed them. As for cleaning the carts, she said she didn't know if there was a process in place for cleaning carts regularly or deep cleaning carts. An audit of a second-floor medication cart was conducted on 11/20/24 at 11:20 a.m. with Staff D, LPN. The cart contained three loose pills in the drawers of the cart. The nurse said she didn't know those were back there. The top drawer was observed to have a set of keys in the compartment with medication bottles. The narcotic drawer was observed to have two lighters, a resident wallet, and batteries. Staff D confirmed loose pills should not have been in the cart and said she wasn't aware the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 11 of 20 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 11/21/2024 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 additional items could not be in with the medications. She said each nurse took care of their own medication cart. 3. During an interview on 11/21/24 at 12:25 p.m. the Director of Nursing (DON) stated skin protectants were usually kept in the treatment cart unless a resident had a self-administration completed. Residents Affected - Some On 11/18/24 at 11:21 a.m. and 11/20/2024 at 3:05 p.m., in resident room [ROOM NUMBER] on the window side, a bottle of wound cleanser was observed on the night stand next to the bed. On 11/18/24 at 11:30 a.m. and 11/19/2024 at 4:07 p.m., in resident room [ROOM NUMBER] on the door side, a bottle of ketoconazole shampoo 2% was observed on the night stand next to the bed. On 11/18/24 at 11:33 a.m. and 11/19/2024 at 4:10 p.m., in resident room [ROOM NUMBER] on the door side, 3 packets of [brand name] skin protectant were observed on the night stand next to the bed. On 11/18/24 at 11:24 a.m. and 11/19/2024 at 4:11 p.m., in resident room [ROOM NUMBER] on the window side, a bottle of tolnaftate antifungal powder and packets of [brand name] skin protectant were observed on the night stand next to the bed. On 11/20/24 at 3:18 p.m., in resident room [ROOM NUMBER] (one occupant), an observation of the following: Nicorette gum was in a box on the over bed table. The box was open revealing several packets of the Nicorette gum. A box was on the bed with antiseptic skin cleanser and Triamcinolone Acetonide cream. 4. On 11/20/24 at 11:05 a.m., an observation was conducted of the first hallway medication storage room with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM). The refrigerator for narcotics had a large padlock lock unlocked. Inside the refrigerator, the narcotic black box was secured to the floor of the refrigerator but also unlocked. In the narcotic box was a syringe of Lorazepam injectable. Staff L, LPN/UM stated she was unaware the narcotic box needed to be locked. On 11/20/24 at 11:15 a.m., an observation was made of Med Cart 1 high with Staff L, LPN/UM An observation was made of loose pills throughout the cart. Staff L, LPN/UM stated the medication cart was cleaned Monday. A review of the facility's policy titled, Storage of Medications, showed the following policy statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. The policy interpretation and implementation showed the following: 1. Drugs and biologicals used in the facility 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. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . 7. Antiseptics, disinfectants, and germicide used in any aspect of resident care have legible, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 12 of 20 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 11/21/2024 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 distinctive labels that identify the contents and the directions for use and are stored separately from regular medications . 10. Resident medications are stored separately from each other to prevent the possibility of mixing medications between residents. Residents Affected - Some 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses 'station or other secured location. Medications are stored separately from food and are labeled accordingly . 13. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 13 of 20 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 11/21/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accommodate food preferences for two residents (#90 and #263) of six sampled residents. Findings included: 1. On 11/18/2024 at 11:51 a.m. Resident #90 was observed sitting in front of the lunch meal. Resident #90's meal ticket showed, NO RICE, No POTATO, NO PACAKES [sic] NO WAFFLES NO FRENCH TOAST DOUBLE VEGGIES!!! Resident #90 had rice on the plate. Resident #90 refused to eat the rice, and no other options were provided. During an interview on 11/18/2024 at 11:51 a.m. Resident #90 stated, I never get what I am supposed to get. Resident #90 continued to state, It doesn't matter how many times I tell people, they just send what they want. I have lost weight while I am here, I have protein shakes brought in to ensure I receive the protein I need for my diagnosis. On 11/20/2024 at 1:50 p.m. Resident #90 was observed sitting in front of the lunch meal. Resident #90's meal ticket showed, NO RICE, No POTATO, NO PACAKES [sic] NO WAFFLES NO FRENCH TOAST DOUBLE VEGGIES!!! Grilled Cheese, Baby Carrots, Savory Chicken Noodle Soup, Pudding and choice of beverage. Resident #90 had carrots on her plate, a grilled cheese, pudding and juice, but no chicken noodle soup. (Photographic Evidence Obtained) Review of Resident #90's admission Record revealed the resident was admitted on [DATE]. Diagnoses included end stage hypertensive heart and chronic kidney disease without heart failure, with end stage renal disease, dependence on renal dialysis, and type 1 diabetes. Review of the Minimum Data Set (MDS) assessment, dated 11/8/2024, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15/15, which meant the resident was fully cognitively intact. Review of the Order Summary Report of active physician orders, dated 11/21/24, revealed: - controlled carbohydrate diet, Regular texture, thin consistency, order and start date 10/15/2024 - Pro Stat one time a day for end stage renal disease, give 30 ML (milliliter) may mix with beverage of choice, order dated to start 10/23/2024. The care plan for Resident #90 revealed the following focus areas: - Potential for complications related to hemodialysis for diagnosis of ESRD (end stage renal disease), dated 10/16/2024. Interventions included: Consult with dietitian PRN (as needed) for nutritional support r/t (related to) renal disease . ,dated 10/16/2024. - [Resident #90] has nutritional problem or potential nutritional problem r/t post BKA (below the knee amputation), skin integrity, THERAPEUTIC DIET, AND DIAGNOSIS OF PVD (peripheral vascular disease), DM TYPE 1 (diabetes mellitus), ESRD ON HD (hemodialysis), dated 10/21/2024. Interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 14 of 20 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 11/21/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included: The resident will maintain adequate nutritional status as evidenced by no s/s of malnutrition, and consuming at least 50% of meals thru next review; Monitor/record/report to MD (Medical Doctor) PRN s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months; Provide and serve supplements as ordered: liquid protein x 30 days; Provide, serve diet as ordered. Monitor intake and record q (every) meal, dated 10/21/2024. 2. During an interview on 11/18/2024 at 11:21 a.m. Resident #263 stated she requested several times for no gravy on the food served and continues to receive it. On 11/19/2024 at 11:55 a.m. Resident #263 was observed with a lunch tray. Resident #263's meal had chopped meat smothered in a brown gravy. Resident #263 stated, I am not going to eat that, I have told them, no gravy. No other option was provided for the resident. During an interview on 11/20/2024 at 2:55 p.m. the Certified Dietary Manager (CDM) stated a therapy aide completes resident choices daily including likes and dislikes. The CDM continued to state meetings are held with all residents upon admission and upon request. The CDM said, I try to speak with them daily in the morning to see if there is anything the resident would like. Upon discussion of the observation of the gravy served to Resident #263 and Resident #90's preferences not being followed, the CDM stated they were not surprised and would need to educate the dietary staff, again. The CDM stated the tray tickets should be followed. Review of the facility's policy and procedure titled, Resident Food Preferences, undated, showed: Policy Statement: individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diets will only be ordered with the resident or representative's consent. Policy interpretation and implementation: 1. Upon residence admission (or within 24 hours after his/her admission) the dietician or CDM will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. 7. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. 10. The facilities quality assessment and performance improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 15 of 20 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 11/21/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interviews the facility failed to ensure four kitchen staff members (Certified Dietary Manager, A, B, and C) wore hairnets, beard guards and gloves in accordance with professional standards for food service safety, in one of one kitchen observed. Findings included: During the initial tour of the kitchen on 11/18/24 at 9:05 a.m., Staff A, [NAME] was observed with uncovered facial hair, standing over a pot on the stove stirring the contents with no beard guard in place. An additional observation at this time revealed the Certified Dietary Manager (CDM) standing at a prep table with no hairnet in place. During an interview on 11/18/24 at 9:05 a.m. the CDM stated she was just at morning meeting and she came straight to the kitchen and began working. The CDM stated she just forgot to put a hairnet on after the morning meeting. The CDM stated Staff A, [NAME] should have a beard guard on. An observation on 11/18/24 at 4:15 p.m. showed Staff B, Dietary Aide (DA) with facial hair standing over a large metal bowl with no beard guard in place. During an interview on 11/18/24 at 4:15 p.m. the CDM stated that all employees with facial hair should be wearing a beard guard. The CDM turned to Staff B, DA and told him to put a beard guard on. Staff B, DA responded and said he didn't know where the beard guards were, and the other male kitchen staff showed him where the beard guards were located. An observation on 11/20/24 at 11:26 a.m. showed Staff C, DA walked over to a kitchen table and opened a loaf of bread with her bare hands. Staff C, DA was observed taking out slices of bread and laying the bread on the covered table without washing her hands and without gloves. Staff C, DA took out a total of eight slices of bread without gloves. The Regional Dietitian (RD) was observed informing Staff C, DA that the bread needed to be discarded, hands washed and to put gloves on prior to proceeding in making sandwiches. During an interview on 11/20/24 at 11:26 a.m. Staff C, DA stated that she knew she was supposed to be wearing gloves when working with food, but got so busy today, and that sometimes she wears gloves and sometimes she does not. During an interview on 11/20/24 at 12:43 p.m. the CDM stated Staff C, DA had been educated in the past regarding wearing gloves. Review of the facility's policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated October 2017, showed, Policy Statement: Food and nutritional services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 8. Contact between food and bare (ungloved) hands is prohibited. 12. Hair nets or caps and/or beard restraints must be worn from contacting exposed food, clean equipment, utensils and linens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 16 of 20 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 11/21/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility did not ensure appropriate infection control practices on two of two units related to respiratory equipment being left uncovered for one (#103) of one resident sampled for respiratory concerns, an ice scoop left uncovered in a hall, handling of clean linens, cleaning of glucometers, and contact precautions for one (#263) of two residents sampled for transmission-based precautions. Residents Affected - Few Findings included: 1. An observation and interview was conducted on 11/19/24 at 10:05 a.m. in the room of Resident #103. There was a respiratory mask sitting on the bedside table uncovered. The resident said she does not routinely get breathing treatments, only when needed. She said staff leave the respiratory mask on the table uncovered just like it is. Review of admission Record showed Resident #103 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of Resident #103's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns, showed she had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of Resident #103's November 2024 physician orders showed an order for Ipratopium-Albuterol Solution 0.5-2.5mg (milligrams)/3ml (milliliters). Give 3 ml inhaler every 6 hours as needed for shortness of breath or wheezing, dated 10/22/24. An observation was conducted on 11/20/24 at 9:09 a.m. during medication administration with Staff E, Licensed Practical Nurse (LPN). The nurse was observed getting a glucometer and a bottle of glucose test strips, entering a resident room, donning gloves, and pricking a resident's finger for a blood glucose check. She wiped the resident's finger then squeezed the finger to get a drop of blood out. She then put her finger with the same gloves in the container containing glucose test strips. When the nurse exited the resident room, Staff E placed the glucometer on the medication cart prior to cleaning it. The glucometer and bottle of test strips were not labeled with a resident name. The nurse said they tried each resident having their own glucometer, but now she just used one for all residents. An observation was conducted on 11/19/24 at 9:38 a.m. of an ice scoop sitting uncovered on a cart with an ice chest in the 200 hall. The ice scoop remained uncovered at 11:47 a.m. An interview was conducted on 10/21/24 at 3:00 p.m. with the Director of Nursing (DON). She confirmed the nurse should not put her hands with soiled gloves in the bottle with the glucose test strips unless it specifically belongs to that resident. She said glucometers should be cleaned between residents and not be placed on the medication cart prior to being cleaned. The DON said the facility had enough glucometers for each resident to have their own and she didn't know why the nurse was using one for all residents. The DON said the ice scoops in the hall should be placed in the container that is on the cart, they should not be left uncovered. The DON also stated respiratory masks should be placed in a bag/box in the resident room and should not be left uncovered on the bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 17 of 20 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 11/18/24 at 11:31 a.m., Resident #263 was observed lying in bed. The resident's left foot was observed in a Podus type boot with a towel under the heel and a bandage covering the ankle and heel, dated 11/14/24. The residents' toes were exposed. The big toe had what appeared to be dried blood on the outer tip of the toe and nail. The resident room door did not indicate any type of precautions. On 11/20/24 at 9:45 a.m. Resident #263 was observed lying in bed and the resident room door did not indicate any type of precautions. Review of Resident #263's progress notes dated 11/19/24 at 2:36 p.m. showed the resident complained of loose stools. The nurse practitioner (NP) was notified and ordered a stool culture to check for c-diff (Clostridium Difficile). Review of Resident #263's November 2024 Order Summary Report showed an order dated 11/19/2024: collect stool for c-diff. During an interview on 11/20/24 at 11:48 a.m. Staff H, Licensed Practical Nurse (LPN) confirmed Resident #263 had complained of loose stools and the NP ordered a culture for C-Diff. Staff H, LPN confirmed no precautions were taken at this time. Staff H, LPN stated resident's only go on precautions if when the test results are back and positive for the infection, No precautions are needed yet. If a resident were to need precautions, signs are placed on the door to inform staff of resident needs. Staff H, LPN confirmed Resident #263 is sharing an IV (intravenous) medication pole with another resident who is in need of IV medication. During an interview on 11/21/24 at 12:25 p.m. with the DON and acting Infection Preventionist (IP) stated, Residents who have an order for C-diff are not isolated right away, there is limited space for isolated residents, and it doesn't always come back positive. As soon as we get the result we isolate if positive. If a resident were sharing equipment, bleach wipes would need to be used to clean the equipment. Staff would know this based on the isolation sign on the door. The DON/IP continued to state respiratory equipment should be stored in a plastic bag, that is dated when not in use. During an interview on 11/21/24 at 3:30 p.m. the Nursing Home Administrator (NHA) stated the facility follows CDC (Centers for Disease Control and Prevention) guidelines. Review of the facility policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, undated showed the following: - Policy Statement: transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; Arrives for admission with symptoms of an infection; Or has a laboratory confirmed infection; and is at risk of transmitting infection to other residents. - Policy Interpretation and Implementation: . 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 3. The Centers for Disease control and prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that the personnel and visitors are aware of the need for any and the type of precaution. The signage informs the staff of the type of CDC (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 18 of 20 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few precaution(s), instructions for use of PPE (Personal Protective Equipment), and/or instructions to see a nurse before entering the room. Signs and notifications comply with the resident's rights to confidentiality or privacy. 6. When transmission-based precautions are in effect, non-critical resident care equipment items such as stethoscopes, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. - Contact Precautions: 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the residents environment. 3. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the infection preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with low-risk roommate). 4. Staff and visitors wear gloves (clean non sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed and hand hygiene performed before leaving the room. Staff will avoid touching potentially contaminated environmental surfaces or items in the residence room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Review of the facility policy and procedure titled, Clostridium Difficile, undated, showed the following: - Policy Statement: Measures are taken to prevent the occurrence of Clostridium Difficile Infection (CDI) among residents. Precautions are taken while caring for residents with C difficile to prevent transmission to other residents. - Policy Interpretation and Implementation: . 3. The primary reservoirs for C difficile are infected people and surfaces. Spores can persist on resident care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. 4. C difficile is transmitted via the fecal oral route. Therefore, any resident care activity that involves contact with the residents mouth when hands or instruments are contaminated may provide an opportunity for transmission, for example: oral care/suctioning; . administration of oral medications; . 5. Steps toward prevention and early intervention include; ongoing surveillance of CDI; increasing awareness of symptoms and risk factors among staff, residents and visitors; considering C difficile and differential diagnosis, especially in residents with symptoms or risk factors; frequent hand washing with soap and water by staff and residents; wearing gloves when handling feces or articles contaminated with feces; disinfection of items with potential fecal soiling (e.g., bed pans, commode chairs, bed rails, etcetera.) Using disinfecting agent recommended for C difficile (e.g., household bleach and water solution or an EPA registered germicidal agent effective against C difficile spores); and removal of environmental sources of C difficile (ie., replacement of electronic thermometers with disposables). 9. Residents with diarrhea associated with C difficile (i.e., residents who are colonized and symptomatic) are placed on contact precautions. Review of the facility policy and procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, with a revision date of November 2011, showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 19 of 20 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. - Steps in the Procedure: Infection Control Considerations Related Oxygen Administration . 3. [NAME] bottle with date and initials upon opening and discard after 24 hours. 7. Change the oxygen cannula and tubing every seven (7) days or as needed. 8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: . 7. Store the circuit [mask/pipe/tubing, etc] in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set up every seven (7) days. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 20 of 20