Health inspection·November 19, 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 observation, interview, and record review, the facility failed to ensure that Certified Nurse Assistant (CNA) 1 was not assigned to a resident (Resident 1) after Resident 1 requested not to receive care from CNA 1 for one of three sampled residents (Resident 1). This deficient practice had the potential to upset and cause emotional distress to Resident 1. Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified anxiety disordered (a mental health condition characterized by persistent and extreme worry) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 1 had the capacity to understand and make decisions. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) from staff with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. During an interview on 11/18/2025 at 3:19 p.m., Resident 1 stated on 10/30/2025, CNA 1 was assigned to her during the 3-11 p.m. shift and refused to provide a shower. Resident 1 stated she informed Licensed Vocational Nurse (LVN) 1 that she did not want CNA 1 assigned to her. Resident 1 stated a different CNA (CNA unknown) was subsequently assigned. During a review of the Change of Condition Evaluation (COC), dated 10/30/2025, indicated Resident 1 requested not to be assigned to CNA 1 and asked for a different CNA. The COC indicated CNA 2 was subsequently assigned to Resident 1. During a telephone interview on 11/19/2025 at 9:48 a.m., CNA 1 stated she was assigned to Resident 1 on 11/1/2025 and did not know she was not to be assigned to her. CNA 1 stated her assignment was changed and no longer was assigned to care for Resident 1. During a telephone interview on 11/19/2025 at 12:00 p.m., LVN 1 stated on 10/30/2025 Resident 1 stated she did not want CNA 1 to care for her. LVN 1 stated when a resident does not want a certain staff member to care for them, the request is communicated to everyone (nursing staff) and documented in the communication book. LVN 1 stated he was not aware of Resident 1's preference as it was not documented in the communication book. LVN 1 stated had he had known Resident 1 did not want CNA 1 to be assigned to her, he would have assigned Resident 1 a different CNA. LVN 1 stated it is important to honor Resident 1's request because it is their right.During an interview on 11/19/2025 at 2:21 p.m., Restorative Nursing Assistant (RNA) 1 stated he made the CNA assignment on 11/1/2025 and was not aware of Resident 1's nurse preference until after LVN 1 told him. RNA 1 stated you must honor a resident's preference because it is their right. During an interview on 11/19/2025 at 12:59 p.m., the Director of Nursing (DON) stated she was aware of Resident 1 not wanting CNA 1 to provide care for her. The DON stated that when a resident refuses care from a specific nurse, the information is documented in the communication book. The DON stated that honoring such preferences is important as it relates to resident rights and dignity. During a review of the facility's policy and procedure (P&P), titled Residents Rights, revised 8/2009, the P&P Page 1 of 2 056192 056192 11/19/2025 Harbor Post Acute Care Center 21521 S. Vermont Avenue Torrance, CA 90502

F 0550 indicated residents are guaranteed the right to voice grievances and to receive a response, as required by federal and state laws. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056192 Page 2 of 2