Health inspection·April 8, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to ensure one of three resident's (Resident 1) right to be treated with dignity when a Certified Nursing Assistant (CNA 1) removed bra while in Resident 1's room. This facility failure had the potential to result in a loss of dignity for Resident 1. Findings: During a review of Resident 1's admission Record, dated 4/2/2025, the admission Record indicated in part, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: muscle weakness, aphasia (language disorder that results from brain damage), type 2 diabetes mellitus (the body cannot use insulin [a hormone which regulates the amount of glucose in the blood] correctly and sugar builds up in the blood), cerebral infarction (disrupted blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS), (a standardized assessment tool to evaluate the health and functional abilities of residents) dated 2/28/2025, the MDS indicated, a Brief Interview for Mental Status ([BIMS] a brief screener to detect cognitive impairment) score of 15 (13 - 15 cognitively intact). During an interview on 4/7/2025 at 1:08 p.m. with the administrator (ADMIN), ADMIN verbalized CNA 1 admitted to removing bra and said it was hot and went behind the curtain and stored the bra in Resident 1's closet. ADMIN stated, We just confirmed that she broke company policy. During a telephone interview on 4/15/2025 at 2:26 p.m. with the Director of Nursing (DON), the DON verbalized it's within the facility policy about employee of sharing personal information .What wasn't followed was sharing personal information like a phone number. During a review of final summary, dated 04/02/2025, the final summary indicated, On 03/27/2025, resident (Resident 1's name) sent an email addressed to Administrator (name), describing verbal, emotional, and physical abuse by CNA 1. (Resident 1's name) also wrote has been sexually harrased by (CNA 1's name) .Resident 1 stated an incident occurred when (CNA 1's name) went into (Resident 1's) room and said (CNA 1) felt hot. Resident stated (CNA 1's name) then went behind the curtain in the room so CNA 1 would not be seen as the bra was removed. CNA (CNA 1's name) stated that they are friends .(CNA 1's name) was asked if (she/he) has ever changed (his/her) clothing in front of the resident. (CNA 1's name) stated, I just take off my bra. Not in front of Resident 1 but in front of B bed, Resident 1 was in A bed. (CNA 1's name) explained that the bra was removed behind a curtain and the resident was not able to see . Investigation conclusion at this time, the facility can confirm that (CNA (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055342 Printed: 05/15/2026 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 055342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Thousand Oaks Post Acute, LLC 93 West Avenida DE Los Arboles Thousand Oaks, CA 91360 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)