Health inspection·May 1, 2025

F 0622 Level of Harm - Actual harm Residents Affected - Few home with her [family member] upon improvement of her condition. Interventions included to discuss with resident/family representative discharge planning process. Investigate needs for returning home such as cooking, cleaning, shopping, medical equipment, financial resources, meals, pharmaceutical needs, physician follow- up, respite care, Home healthcare, Lifeline, adult protective service, live- in care provider transportation etcetera. Review of a Physical Therapy (PT) discharge summary evaluation dates of service 1/20/2025 - 4/11/2025 showed a goal for transfers, patient will safely perform functional transfers with Min [minimal] A [assist] with reduced risk for falls in order to decrease level of assistance from caregivers. Under comments it showed, transfers continue to vary from Mod A [moderate assistance] x1 (person) to assist x2 (persons]. Therapy recommended use of sit to stand at home for safety. For ambulation: it showed, patient will ambulate up to 60 ft (feet) with upright RW [Rollator walker], CGA [Contact Guard Assist], in order to safely enter/exit her bathroom at home. The evaluation showed at discharge on [DATE] the resident was ambulating 35 ft with upright FWW [Front Wheeled Walker], CGA, WC [Wheelchair] to follow. For standing, the goal showed patient will increase dynamic standing balance to fair- spontaneously righting self when needed in order to reduce the risk for falls and prepare for transfers. At discharge on [DATE], the assessment showed Resident #1's performance was fair, Min (A) [minimal assist or UE [upper extremity] support to stand w/o [without] LOB [Loss of Balance] and to reach ipsilaterally [on the same side of the body], unable to weight shift. The evaluation revealed the resident could stand- supported for a duration of 1-3 minutes. Discharge recommendations showed wheelchair as primary mode of mobility, sit to stand lift, lift chair, upright walker for ambulation as tolerated, home health services. Review of an Occupational Therapy (OT) progress note for Resident #1 dated 04/16/2025 revealed, discussed recommended equipment for home which includes bedside commode, toileting aide, female urinal, reacher, sock aid, hospital bed, 2ww [wheeled walker], upright walker, [NAME] [sit-stand] lift. Review of a social services progress note for Resident #1 dated 04/22/2025 showed, in home medical provider has delivered a hospital bed, 3:1 commode and wheelchair for Resident #1 . Social Services is having difficulty locating a sit to stand lift. Social services was told by multiple DME (Durable Medical Equipment) organizations that the product is on back order and or items are being leased. This writer reached out to Medicaid case worker to see if transitional funds could purchase the lift for Resident #1. Social services awaiting response from Medicaid. Review of a social services progress note for Resident #1 dated 05/01/2025 showed this writer spoke with Resident #1 upon returning home. She was approved for 28 hours of caregiver services . a schedule has not been established as of yet . Resident #1 inquired about when she would be receiving the upright walker and reclining lift chair. This writer states she will reach out to Medicaid case worker to follow up. Resident #1 also asked about bathroom modifications and furniture removal. An e-mail was sent to Medicaid case worker for follow - up. Review of a psychology progress note for Resident #1 dated 04/08/2025 revealed Resident #1 reported feeling sadness and worry. She reported that she is going home this week and feels overwhelmed with setting her home to be ready for her arrival. She reported worry, thoughts rumination and anxiety. She reported that she has an outpatient psychiatric provider. She will continue treatment with. Feelings explored and validated. Short term goal explored with the patient, who engaged in therapy and intervention. Psychologist collaborated with the patient to explore coping strategies to manage negative mood symptoms using psychoeducation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 2 of 4 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 05/01/2025 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 0622 Level of Harm - Actual harm Residents Affected - Few Review of a psychology progress note for Resident #1 dated 04/02/2025 revealed Resident #1 reports some increased anxiety this week due to personal stressors and uncertainty about her future. She has been given 30-days' notice due to financial issues and is expected to move home with her [male family member]. She worries about her independence and being able to care for herself. She admits her [male family member] can help some but is looking into home health. Review of a social services progress note for Resident #1 dated 03/18/2025 revealed, 30-day nursing home transfer and discharge notice issued to residents. Copy of notice provided to residents. Pt (patient) verbalizes that she is aware of reason for discharge -states She is not paying her portion of what is due. Copy of discharge notice to be sent to ombudsman office. Review of a social services progress note for Resident #1 dated 04/01/2025 revealed, this writer spoke with the Ombudsman Office who confirms Resident #1 has filed a fair- hearing appeal. The appeal was filed on 3/31/2025. Due to not meeting the 10-day deadline, discharge may move forward. Should the resident win the appeal it is understood that she will re-admit to the facility. Review of the Nursing home transfer and discharge notice revealed a notice was given on 3/18/2025. Reason for discharge or transfer: Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay. The notice was presented by the Nursing Home Administrator (NHA) and signed on 3/18/2025. Resident or resident representative signed on 3/18/2025. Review of the State of Florida Department of children and family's office of appeals hearings order revealed a request for a hearing was filed by the petitioner on 3/28/2025. The request is based on an action by the respondent to discharge the petitioner. Review of a social services progress note for Resident #1 dated 04/04/2025 revealed, facility received letter from office of appeal hearings. Resident #1 filed her appeal on 3/28/2025. The ombudsman office was notified on 3/31/2025. Requested documents have been sent to the appeals officer. Review of the order scheduling hearing for Resident #1 revealed a hearing was scheduled for Tuesday, May 6, 2025, time 1:00 PM, place: by telephone. Review of resident #1's Discharge summary dated [DATE] showed, patient discharged at 11:45 am with all medications and narcotics except OTC [Over The Counter] meds. Patient understood medication regime and ileostomy teaching done weeks prior to discharge, and she is fluent with ostomy changing and care. All belongings packed up and sent with pt. All discharge instructions are sent with patient. During an interview on 05/01/2025 at 12:49 p.m., the Social Services Director (SSD) stated Resident #1 was issued a discharge notice in March for nonpayment. She stated the ombudsman had notified the facility Resident #1 had filed an appeal. The SSD stated since the resident filed the appeal on the 11th day, they could continue with the discharge. During an interview 05/01/25 at 2:28 p.m. the Department of Children and Families, office of Appeals Hearings office administrator confirmed Resident #1 had appealed the discharge from the facility and had an upcoming hearing scheduled on May 6, 2025, at 1 p.m. The office administrator confirmed the facility, and the resident had been furnished copies of the hearing notice. During an interview on 05/01/2025 at 3:34 p.m., the NHA stated Resident #1 was discharged prior to her appeal date because she filed the appeal on the 11th day. The NHA confirmed knowing the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 3 of 4 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 05/01/2025 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 0622 had a pending appeal prior to her discharge. The NHA confirmed the facility had received the hearing notice for the upcoming hearing on May 6, 2025. Level of Harm - Actual harm Residents Affected - Few Review of a facility policy titled Transfer or Discharge notice dated December 2016 showed a policy statement, our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Policy interpretation and implementation showed: 3. The resident and/or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is being transferred or discharged . d. A statement of the resident's rights to appeal the transfer or discharge, including: (1). The name, address, email and telephone number of the entity which receives such requests. (2). information about how to obtain, complete and submit an appeal form; and (3). how to get assistance completing the appeal process. 11. In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106079 If continuation sheet Page 4 of 4