Health inspection·April 25, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 record review, the facility failed to ensure one (Resident #5) of five sample residents had access to his wheelchair during one of one days of survey. Residents Affected - Few Findings included: On 04/25/24 at 10.21 a.m., Resident #5 was heard yelling from the hallway saying, I need my wheelchair, somebody please give me my wheelchair, I would like to go and have a cigarette, somebody please . During an observation and interview on 04/25/24 at 10:25 a.m., Resident #5 was observed sitting in the middle of his bed. An interview with the resident revealed he was dependent on his wheelchair to ambulate. He stated he had not had access to his chair all night. He said, I am upset. I need my wheelchair. I want to go out and smoke. Resident #5 was admitted to the facility on [DATE] with diagnoses to include acquired absence of left leg below the knee, muscle wasting and atrophy, generalized muscle weakness, other abnormalities of gait, and presence of left artificial hip joint. Review of a quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Section GG showed Resident #5 had upper and lower extremities impairment and was dependent on a wheelchair for mobility. Under GG0170, the resident was assessed a 6 which indicated he was independent to ambulate 50 -150 feet once seated in a wheelchair and make two turns. On 04/25/24 at 10:27 a.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA). She stated the resident had been yelling about his wheelchair all morning. She confirmed the resident was dependent on his wheelchair for mobility. She stated Housekeeping sometimes removed chairs for cleaning. She stated she did not know if that was the case with the resident's chair. An interview was conducted with Staff B Licensed Practical Nurse (LPN)/ Unit Manager on 04/25/24 at 10:28 a.m. He stated the resident did not have his wheelchair because it was removed for cleaning. He stated they were probably waiting for it to dry, and he did not know how long the resident had been without his chair. He stated he did not know if the resident needed his chair. He said, no one told me. I was there earlier and administered his medications. Staff B stated he did not hear the resident yelling out for his wheelchair. He said, It can be noisy around here. I did not hear him. He confirmed Resident #5 depended on his wheelchair to ambulate. He stated the housekeeping staff should Page 1 of 2 105690 105690 04/25/2024 Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756

F 0558 return chairs to the residents promptly. He stated he would find the resident's wheelchair. Level of Harm - Minimal harm or potential for actual harm On 04/25/24 at 10:32 a.m., an interview was conducted with the Traveling Director of Nursing (DON). She stated regardless of the reason for removing a chair from the resident, they should always have an alternate wheelchair. She said, I can see how removing the wheelchair could limit his ability to move. We will assist him. Residents Affected - Few An interview was conducted on 04/25/24 at 10:38 a.m. with the Director of Rehabilitation (DOR). She said, If a resident's wheelchair is removed for cleaning, they should give him an alternate. They are supposed to let therapy know so that a safe wheelchair is provided. I did not know they removed the chair and did not provide him with a way to move around. I understand how that is restricting his movement. We will get him another chair. The DOR confirmed this resident was dependent on his wheelchair to ambulate. She stated when he was in his wheelchair, he ambulated independently. She stated she would discuss the concern with the housekeeping supervisor so they could collaborate on providing an alternate chair. She stated therapy had extra wheelchairs that could be used as an alternate. She said, They just needed to let me know. On 04/25/24 at 3:25 p.m., Staff B, LPN stated he had followed up and confirmed a housekeeping aide had removed the wheelchair from Resident #5 the previous night around 9:00 p.m. He stated he was supposed to return it. He stated the housekeeping aides were responsible for ensuring the wheelchairs were returned to the residents. He stated they were educating them to only pull the chair if they had a replacement. During an interview with the Nursing Home Administrator (NHA) on 04/25/24 at 4:32 p.m., she stated wheelchair cleaning was conducted between 7:00 p.m.- 9:00 p.m. by floor techs. She stated they had a schedule for cleaning wheelchairs when the residents were in bed. She confirmed each resident who was dependent on a wheelchair should have access to a safe chair while theirs was being cleaned. She said, No, they should not have removed it a whole night. Somebody should have gotten it first thing in the morning. Staff should not take away the resident's ability to self-ambulate. The NHA stated they had initiated education. Review of a facility policy titled, Resident Rights', dated February 2021 showed the facility strives to assure that each resident has a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. # 105690 Page 2 of 2