Health inspection·September 16, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide activities of daily living (ADLs) related to hygiene and bathing in accordance with residents' needs and preferences to 4 out of 5 sampled residents.These deficient practices resulted in residents not receiving showers as preferred, substitution of bed baths for showers, delays in morning care routines, late arrival to activities, and negative impact on residents' dignity and psychosocial well-being.Findings: a. During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 4/18/2025, with diagnoses including paraplegia (paralysis of the lower part of the body, including legs), hemiplegia, and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction affecting the right dominant side. During a review of Resident 1's History and Physical (H&P), dated 4/19/2025 the H&P indicated Resident 1 had the mental capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/24/2025, the MDS indicated the resident's cognitive skills (ability to think and process information) for daily decision making was intact. The MDS indicated the resident was dependent on nurses for toilet use and transfers, was not able to walk, and needed extensive assistance with bed mobility, personal hygiene, and dressing. The MDS indicated Resident 1 had one side upper extremity impairment, and both lower extremity impairment. During an interview on 9/16/2025 at 10 AM, Resident 1 stated that she preferred showers instead of bed baths because showers made her feel cleaner. Resident 1 stated staff informed her she could not receive showers due to the unavailability of the Hoyer lift. Resident 1 stated, I'm getting bed baths instead, but I feel cleaner with a shower. b. During a review of Resident 2's admission Record, the admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including morbid (severe) obesity, and Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). During a review of Resident 2's H&P, dated 2/10/2025, the H&P indicated Resident 2 had the mental capacity to make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions making were intact. The MDS indicated the resident was dependent on nurses for toilet use and transfers, was not able to walk, and needed extensive assistance with bed mobility, personal hygiene, and dressing. The MDS indicated Resident 2 had one side lower extremity impairment, and both upper extremity impairment. During an interview on 9/16/2025 at 10:15 AM, Resident 2 stated she received more bed baths than preferred because the Hoyer lift was in use for another resident. Resident 2 stated, The bed baths are okay, but nothing is better than an actual shower. c. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including quadriplegia (paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso), and bed confinement status. During a review of Resident 4's H&P, dated 5/31/2025, Residents Affected - Some Page 1 of 2 056118 056118 09/16/2025 Gladstone Sub-Acute and Rehab Center 435 E. Gladstone St Glendora, CA 91740

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the H&P indicated Resident 4 had the mental capacity to make medical decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decisions making were intact. The MDS indicated Resident 4 was dependent on nurses for toilet use and transfers, was not able to walk, and needed extensive assistance with bed mobility, personal hygiene, and dressing. The MDS indicated the resident had both lower extremity impairment. During an interview on 9/16/2025 at 11 AM, Resident 4 stated he was frustrated about being unable to get out of bed when desired and had been spending more time in bed because staff could not always use the lift to transfer him to the specialized chair. d. During a review of Resident 5's admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease (progressive mental deterioration), and osteoarthritis (chronic breakdown of cartilage in the joints leading to pain, stiffness, and swelling). During a review of Resident 5's H&P, dated 7/1/2025, the H&P indicated Resident 5 could make needs known but could not make medical decisions. During a review of Resident 5's MDS, dated [DATE], the MDS indicated the residents' cognitive skills for daily decisions making were intact. The MDS indicated Resident 5 was dependent on nurses for toilet use and transfers, was not able to walk, and needed extensive assistance with bed mobility, personal hygiene, and dressing. During an interview on 9/16/2025 at 11:15 AM, Resident 5 stated she received more bed baths than she would like and preferred showers because showers made her feel cleaner. Resident 5 stated the lift was not always available to transfer her to the shower chair. During an interview on 9/16/2025 at 12:15 PM, CNA 1 stated that during the past week when only one Hoyer lift was operational across three nursing units, residents experienced delays in getting out of bed in the mornings and some residents had to receive bed baths instead of showers. CNA 1 stated, Residents still attend activities but arrive later than usual. During an interview on 9/16/2025 at 12:30 PM, CNA 2 stated that residents who normally would be up earlier for showers and activities were being transferred later in the day. CNA 2 stated, We often have to give bed baths instead of showers because the lift isn't available. During an interview on 9/16/2025 at 12:50 PM, CNA 3 stated that with one lift available, multiple staff must wait their turn, which slowed morning care routines. CNA 3 stated, Residents are cared for but are getting up later and sometimes miss the start of activities. During an interview on 9/16/2025 at 1 PM, the Activities Director stated that residents continue to attend group activities; however, they have been arriving later than the scheduled start times. Activities usually begin around 7 AM, but in the past month residents have been arriving closer to 10-10:30 AM. The Activities Director attributed the delay to residents not being transferred out of bed on time. During an interview on 9/16/2025 at 3 PM, the Maintenance Supervisor stated that for the past week the facility had one working Hoyer lift because the remote for the second lift was not functioning. He stated that a replacement remote was ordered and a new Hoyer lift had been received but could not be used for weighing residents until calibrated. The Maintenance Supervisor stated that once the new remote arrived, the facility would have three operational Hoyer lifts. During a review of the facility's policy and procedure titled, Showering a Resident, dated November 1, 2017, the policy indicated, Residents are offered a shower at a minimum of once weekly and given per resident request. 056118 Page 2 of 2