Health inspection·May 19, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure Resident 1's preference for a female provider was respected. This failure had the potential to cause psychological effect to Resident 1. Findings: A record review of the facility ' s undated admission Record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnoses that included, Rheumatoid Arthritis (a chronic inflammatory disorder usually affecting the hands and feet) and Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness on one side of the body). An interview on 5/19/25 at 10:28 A.M., with family member (FM) FM 1was conducted. FM1 stated he had attended a care conference with the facility repeatedly on the same issue of not providing his mother a male certified nursing assistant (CNA) to take care of her. FM1 stated his mother does not feel comfortable with a male CNA, but the incident happened again on Thursday 5/8/25 morning and afternoon shifts. FM1 stated Resident 1 cannot recall exact times. An interview on 5/19/25 at 11 A.M., with Licensed Nurse (LN) LN 1 was conducted. LN 1 stated Resident 1 demanded things to be done right away and the staff tried to explain to the resident, but Resident 1 did not listen. LN 1 stated Resident 1 only preferred female staff to take care of her but sometimes it was not feasible. A joint interview on 5/19/25 at 11:20 A.M., with Resident 1 and Social Service Assistant (SSDA) was conducted. Resident 1 stated she wanted and trusted SSDA to interpret what she had to say, and no one else. Resident 1 stated the facility was aware she cannot have male CNAs but she had a male CNA that assisted to her care last week on a Thursday (5/15/25). Resident 1 stated she told CNA 1 she does not like to be handled by CNA 2 (male CNA), but CNA 1 responded there was no one else available right now and proceeded to pull her briefs up during a brief change in Resident 1 ' s bathroom. Resident 1 stated she did not like her skin exposed to CNA 2 and that made Resident 1 very upset, uncomfortable and did not like it. An interview on 5/19/25 at 2:46 P.M., with CNA 1 was conducted. CNA1 stated, she had to asked another CNA to help her, due to her left arm was hurting. CNA 1 stated she asked CNA 2 since there was no one else available at that time. CNA 1 stated she told resident 1 and she responded, I don ' t like a male CNAs, but we had to proceed with her care, since Resident 1 did not want to wait. CNA 1 Page 1 of 2 555723 555723 05/19/2025 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0561 stated it was important to respect Resident 1 ' s rights preference. Level of Harm - Minimal harm or potential for actual harm An interview on 5/19/25 at 2:57 P.M., with CNA 2, was conducted. CNA 2 stated he was asked by CNA 1 to help her with Resident 1' s care. CNA 2 stated, Resident 1 needed to be changed while in the bathroom. CNA 2 stated he helped CNA 1 by standing there holding Resident 1 while being changed by CNA 1. Residents Affected - Few A record review of Resident 1 ' s Minimum Data Set ( MDS - a federally mandated assessment tool) dated 4/2/25 indicated Resident 1' s brief interview for mental status (BIMS) was 14 which meant Resident 1 ' s cognition (thought process) was intact. A review of the facility's documents titled, Nursing Assignments and Sign-in sheet dated, 5/8/25 indicated, there were seven female CNAs listed on the schedule to work for morning shift and eleven female CNAs listed to work in the afternoon shift. On 5/15/25, the Nursing Assignments and Sign-in sheet schedule indicated, there were seven female CNAs listed on the schedule to work for morning shift and seven female CNAs listed to work in the afternoon shift. An interview on 5/20/25 at 11:03 A.M., with the Assistant Director of Nursing (ADON) was conducted. The ADON stated it was important to respect Resident 1 ' s wishes or preference to protect their rights. A record review of Resident 1 ' s undated care plan titled, mood care plan indicated , at risk for altered mood and behavior .prefers care to be provided by females only . According to the facility ' s policy titled , Residents Rights .policy statement indicated, .employees shall treat all residents with kindness, respect and dignity. policy interpretation and implementation .e. self-determination .p.be informed of, and participate in, his or her care planning and treatment . 555723 Page 2 of 2