Health inspection·August 11, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of 3 residents (Residents 2 and 3) based on the facility's policy by failing to: 1. Ensure Resident 2's privacy curtain was closed and the resident's (a movable fabric barrier designed to provide a private enclosure and block views, commonly used in healthcare settings like hospitals and nursing homes to create patient seclusion) inner thighs were covered and were not exposed while the resident was lying on his bed on 8/11/2025.2. Accommodate Resident 3's request to be gentle when providing perineal care (cleaning the private areas of a resident) from Certified Nursing Assistant 1 (CNA 1). This deficient practice had the potential to affect Resident 2 and 3's sense of self-worth and self-esteem which could result in problems with emotional and mental well-being.Findings:1. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2's diagnoses included chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), and muscle weakness. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 8/4/2025, the MDS indicated Resident 2 has moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, shower/ bathe self, upper body dressing, personal hygiene, chair/bed- to chair transfer, toilet transfer, and tub/shower transfer. During an observation on 08/11/2025 at 9:29AM outside Resident 2's room, Resident 2 was sitting on his bed, privacy curtain not closed, the resident was wearing a hospital gown with the resident's legs exposed and no blanket. Resident 2's both legs were far apart, and the resident's inner thighs were visible from the hallway. During a concurrent observation and interview on 8/11/2025 at 10:39AM with CNA 2 outside of Resident 2's room, Resident 2's left inner thigh can be seen in the hallway. CNA 2 stated, It is not okay that we can see Resident 2's inner thighs in the hallway. We need to cover it, because it is Resident 2's privacy and dignity. During a concurrent observation and interview on 8/11/2025 at 10:41AM with the Director of Nursing (DON) outside of Resident 2's room, Resident 2's inner thigh was exposed and can be seen from the hallway. The DON stated, We should pull the privacy curtains to provide privacy to Resident 2. Resident 2's inner thigh should not be seen in the hallway. We need to cover him, because of dignity. During a concurrent observation and interview on 8/11/2025 at 10:42 AM with Resident 2, Resident 2 pulled down his gown and made sure his thighs were covered. Resident 2 stated, Well it is not okay that other residents can see my inner thighs. During a record review of facility's P&P titled, Dignity revised 2/2021, the P&P indicated, each resident shall be cared for in a manner that promotes and Page 1 of 3 055376 055376 08/11/2025 Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P also indicated residents are to be always treated with dignity and respect and staff to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 diagnoses included hemiplegia (paralysis of one side of the body), major depressive disorder ( or also called clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems) and anxiety disorder (a disorder characterized by nervousness characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior [repetitive, persistent, and often uncontrollable actions that a person feels driven to perform] or panic attacks). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 has moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, shower/ bathe self, and chair/bed-to chair transfer. During a review of Resident 3's Care Plan (CP) for at risk for further decline in function, joint mobility, contracture formation, falls, skin breakdown and increased dependence in Activities of Daily Living (ADLs, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), dated 1/14/2022, the CP indicated in the interventions/approaches, needs extensive assistance with bed mobility, w/ 2 persons physical assist, locomotion off unit, dressing, toileting, personal hygiene. During an interview on 8/11/2025 at 10:51 AM, with Resident 3, Resident 3 stated, I am upset because CNA 1 was handling me roughly. CNA1 was changing my diaper. When she is turning me and I told her, you are fucking hurting me. She told me that she will not work with me tomorrow because I was cursing her. I just said the wrong words because she is rough. During an interview on 8/11/2025 at 11 AM with CNA 1, CNA 1 stated, Saturday, Resident 3 pressed the resident's call light and asked me If I can change her. I told her I was going to give another resident a shower, so she needed to wait a little bit. When I came to change her briefs, there was a lot of bowel movement in the vaginal area. I need to clean her pretty well because it went to her creases. She told me, You are hurting me. I am getting bowel movements out of her vaginal area. I tried to clean her private part, but she said you are hurting me and then curse at me and told me to get the F out of my room. The towels might be rough. The washcloths might have rough texture also. But Resident 3 always tells me, I have a heavy hand. She is sensitive and complains of pain in everything. She was probably in a bad mood because she has to wait. During an interview on 8/11/2025 at 12:05PM, with Resident 3, Resident 3 stated, My buttocks hurts when she wiped me in the creases. It hurts every time she wipes. She wipes too hard. I told her she has to be gentle, but She cannot be gentle. She did not care. She said you will be okay. It was fine. Resident 3 also stated that Resident 2 told CNA 1, I am not fine, you are rough. I am telling you. and after that CNA 1 did not change and the resident felt CNA 1 brushed off the resident's complaint, did not listen to the resident and the resident felt disrespected. During a concurrent interview and record review on 8/11/2025 at 12:08PM with the DON, the facility's P&P titled, Accommodation of Needs, revised 3/2025 was reviewed. The P&P indicated, interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity. The DON stated, Interacting Resident's preference meaning Resident 3 wants the resident's care to be individualized and be treated with non-judgmental attitude, dignity and well-being. The DON stated, the way the staff interact with residents should be accommodating on the Resident's preference. If the Resident said you 055376 Page 2 of 3 055376 08/11/2025 Huntington Drive Health and Rehabilitation Center 400 W. Huntinton Dr. Arcadia, CA 91007

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some are hurting me, the staff should stop and ask where it hurts, how am I hurting you. It might cause pain in the Resident. Sometimes it might be the behavior of the Resident but still maintain respect and professionalism. During an interview on 8/11/2025 at 1:38 PM with the Director of Staff Development (DSD), DSD stated, Rough handled during care means they were changing you or wiping you and the staff were acting careless. It can affect the Resident by making them feel sad, emotional, psychological, and their entire well-being. During a record review of facility's policy and procedure (P&P) titled, Patient Rights revised 2/2021, the P&P indicated, federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:> A dignified existence.> Be treated with respect, kindness, and dignity.> Privacy and confidentiality. During a record review of facility's P&P titled, Dignity revised 2/2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances bis or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P also indicated the facility supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. 055376 Page 3 of 3