Inspection·May 15, 2024

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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 2 of 3 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106112 If continuation sheet Page 3 of 3