Gladstone Sub-acute And Rehab Center

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.

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