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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105690 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 105690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Pines Rehabilitation Center 1111 S Highland Ave Clearwater, FL 33756 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)