Health inspection·May 15, 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 reasonable accommodation of needs related to wheelchair use for one (Resident #3) of four sampled residents. Residents Affected - Few Findings included: On 5/15/24 at 10:18 a.m., Resident #3 was observed using his phone while lying down in bed. Resident #3 reported he had resided at the facility for 2 years. Resident #3 stated his concern of not having a wheelchair at that time. He stated he had spine surgery and had difficulty walking. Resident #3 revealed he was dependent on the wheelchair to ambulate. He stated he relied on staff to get him in and out of bed and into the wheelchair. He stated staff used the [Mechanical] lift with two people assisting him. Resident #3 stated he did not have a wheelchair at that time because it was being borrowed. He stated one staff member asked for his permission to take the wheelchair because it was needed for measurements. He stated he could not remember who the first staff member was. He said a second occurrence of borrowing the wheelchair happened two days ago. He stated Staff D, Unit Manager (UM)/Registered Nurse (RN) asked for his permission to borrow the wheelchair he used. Resident #3 stated the wheelchair had not been returned for his use. A second interview with Resident #3 on 5/15/24 at 10:46 a.m. revealed he had not been able to get out of bed for two days. He stated if he wanted to get out of bed he could not because he did not have access to the wheelchair at that time. He stated his family came to visit and they did not take him out because he did not have his wheelchair. Resident #3 stated, I feel like I'm being picked on. Why did they take this wheelchair and not someone else's? A review of the admission Record for Resident #3 showed an admission date to the facility of 7/18/22 and diagnoses to include history of falling, low back pain, unspecified, muscle spasm of back, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness (generalized), contracture, left knee, and pain in left knee. A review of Resident #3's care plan initiated on 7/19/22 showed a focus of, [Resident #3] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] morbid obesity, history of CVA [Cerebrovascular accident] with left side weakness, activity intolerance, deconditioning. The goal, with an initiated date of 12/23/22, a revision date of 5/13/2024, and a target date of 5/25/24, revealed the following: The resident will maintain current level of function in ADLS through the review date. The interventions included the following: LOCOMOTION: The resident uses a wheelchair for locomotion. A review of the medical record to include progress notes and current care plan showed there was no Page 1 of 3 106112 106112 05/15/2024 Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549

F 0558 documentation of Resident #3 refusing to get out of bed. Level of Harm - Minimal harm or potential for actual harm A review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Section GG - Functional Abilities and Goals showed the following: Residents Affected - Few - Mobility Devices - B. Wheelchair, response: yes. A review of Resident #3's Therapy Screen dated 5/2/24 showed the current level of transfer is dependent and ambulation is none. An interview conducted on 5/15/24 at 11:02 a.m. with Staff D, UM/RN. She revealed she asked permission from Resident #3 to borrow the wheelchair and her intention was not to take it indefinitely. She stated before borrowing the wheelchair from Resident #3, she confirmed with the Director of Therapy/Physical Therapist (PT), it belonged to the facility . She stated Resident #3 was hesitant at first and told her, It's mine. She stated after explaining to Resident #3 that it was to try on another resident, then he gave permission. She stated the wheelchair was borrowed to see if it fit another resident who resided in another room on the unit. Staff D confirmed it was therapy's role to evaluate if the wheelchair fit or not. Staff D confirmed Resident #3 needed assistance with ADLs and ambulating. Staff D was aware Resident #3 had not been out of bed since she took the wheelchair out of his room. She stated the resident sometimes refused to get up. Staff D stated she had not returned the wheelchair yet. An interview conducted on 5/15/24 at 11:25 a.m. with the Director of Therapy/PT. He revealed Resident #3's wheelchair was borrowed to assess another resident. He stated, Taking [Resident #3's] wheelchair was the quickest way to do it. The Director of Therapy stated the trial/assessment should not take long to complete. He confirmed therapy staff normally did the trial/assessment for residents. The Director of Therapy stated [the other resident] was on the caseload today, 5/15/24, for assessment with Resident #3's wheelchair. He stated, We haven't got to that point yet. The plan is to do it today. The Director of Therapy stated he was not aware Staff D removed the wheelchair from Resident #3 ahead of the assessment with therapy and that it was not returned. He stated Resident #3 did not like to get out of bed. The Director of Therapy stated if the wheelchair was Resident #3's personal property he would not have taken it and would have respected his wishes if Resident #3 said no to taking the wheelchair. For residents that need to be evaluated by therapy, the Director of Therapy stated there was a therapy referral form. He stated staff also communicated face to face or by phone with himself and his team. An interview was conducted on 5/15/24 at 4:16 p.m. with the Director of Nursing (DON). She stated for residents that needed a wheelchair assessment, she expected that the nursing staff would communicate with therapy. The DON stated she spoke to Staff D. She stated therapy wanted to try a specific wheelchair and that was why Staff D borrowed Resident #3's wheelchair. She stated in the conversation with Staff D, she asked Resident #3 if it was okay to remove the wheelchair from his room. The DON agreed that the wheelchair was not returned in a timely manner. She stated she was not sure where the wheelchair was these past two days. She agreed that it was not acceptable that the resident would not have his wheelchair accessible to him. Review of the facility policy titled, Resident Rights, revealed the following in section (a) Resident Rights: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified 106112 Page 2 of 3 106112 05/15/2024 Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549

F 0558 Level of Harm - Minimal harm or potential for actual harm in this section. The policy further revealed in section (1), A Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . Residents Affected - Few 106112 Page 3 of 3