Other·July 24, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health, Licensing and Certification, during an investigation of one Entity Reported Incident (ERI) on a standard abbreviated survey. ERI: CA00590564-Substantiated Representing the Department: 37821-HFEN 40056- HFEN - Trainee The inspection was limited to the specific ERI investigated and does not represent the findings of a full inspection of the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate supervision for one of two residents (Resident 1) who had difficulty swallowing to prevent choking during dinner. As a result of this failure, Resident 1 choked and died at the facility while eating LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dinner on 4/6/18. Findings: Record review of Resident 1's face sheet dated 5/18/16 indicated Resident 1 was re-admitted with a diagnoses to include oral phase dysphagia (difficulty swallowing). Review of "BD [facility name] Nursing Admission Data Collection - V 6" dated 3/21/18 revealed, Resident 1 was alert, oriented to person, short term memory ok, with clear speech. Review of the facility order summary on the "Medication Review Report" dated 3/22/18 and Nutrition Risk Review" dated 3/27/18 revealed, Resident 1 was on the texture modified (moist, soft-solid, meat and poultry are ground), regular fluid consistency, with chewing difficulty, and dining ability as "assistance/cueing needed/slow." Review of the facility's comprehensive assessment dated 03/28/18 indicated Resident 1 required supervision including: cueing, encouragement, oversight, and setup help to eat. Review of Resident 1's "Order Summary Report" dated 3/21/18 revealed Speech Therapy (ST) treatment for dysphagia daily five times a week times four weeks, plan of care to include diet modification and swallow safety guideline implementation to maximize safety with intake and decrease risk of choking/aspiration. Review of the facility's care plan interventions for "nutritional problems" and "alteration in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE gastro-intestinal status" both dated 04/04/18 listed interventions including ST evaluation and treatment, and staff to encourage the resident to take time eating and to alternate food with sips of fluids. Review of Resident 1's ST assessment and plan of care dated 3/22/18 indicated "new onset of decreased oral/pharyngeal function, increased signs and symptoms of dysphagia and coughing/choking during oral intake placing patient (Resident 1) at risk for aspiration, decreased ability to return to prior level of supervision, pneumonia and further decline in function." The ST assessment indicated Resident 1 required close supervision during meals with cuing, taking small bits, chewing, tilting head and swallowing with a sip of water. The assessment indicated Resident 1 had poor safety awareness. Review of "Speech Therapy (ST) Daily Treatment Encounter" dated 3/26/18 indicated "The patient [Resident 1] was given regular/thin liquid textures to improve diet texture tolerance and safety with intake, with cueing from the ST to take small bites, slow rate of intake, and alternate liquid/solid swallows. The notes indicated even with cueing from ST, "the patient [Resident 1] took larger bites initially with cueing required from ST to decrease bite size. The ST emphasized increased mastication (chewing) to break food down with tougher textures ... would benefit from continued instruction to improve carryover of swallow safety, guidelines including alternation of liquids/solid swallows and smaller bites." The ST recommended continues instructions for Resident 1 for safety. A review of facility's "BD Nutrition Risk Review" dated 3/27/18 indicated Resident 1 had chewing difficulty and needed assistance and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cueing to slow down during meals. The resident was eating and average of 50 percent (%) of her meals on a texture modified diet and her weight was stable. During an interview on 6/28/18 at 10:28 a.m., the dietary supervisor (DS) indicated a texture modified diet consists of food that is moist and soft. All meats and poultry are ground with the exception being small tender pieces of meat allowed in soups. A regular diet has no texture restrictions. A review of the facility's ST Daily Treatment Encounter notes dated 3/27/18 indicated Resident 1 stated she felt nauseous after several bites of regular textures (food) and sips of liquids. The facility's "Progress Note" dated 3/28/18 indicated an order was received from the ST "to change (Resident 1's) diet from texture modified (Mechanical soft) to Regular diet. Review of the ST Daily Treatment Encounter notes dated 3/29/18 indicated Resident 1 "continues to require maximum cueing." The "Speech Therapy Daily Treatment Encounter" notes dated 3/29/18 and 3/30/18 indicated Resident 1 "continues to require maximum cueing to alternate liquid/solid, swallows more frequently, with 50% carryover noted... decreased safety awareness, occasionally attempts to take larger bites and increase rate of intake." The notes dated 4/4/18 indicated Resident 1 "coughed several times" while swallowing. On 4/5/18 the notes indicated Resident 1 "required review of swallow safety guidelines due to attempts to drink thin liquids while not fully upright...with cueing, the patient presents with good carryover of alternation of liquid/solid swallows to 90% with frequent instructions." Although the facility was aware Resident 1 coughed several times while FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE swallowing, took bigger bites of food instead of smaller bites, had decreased safety awareness, felt nauseous after several bites of regular textures and sips of liquids, had chewing difficulty and needed assistance and cueing to slow down during meals, there was no documentation to indicate the facility provided Resident 1 with close supervision and assistance while eating, and did not change the consistency of Resident 1's diet. There was no documentation to indicate the facility educated Resident 1's daughter on how to cue and supervise Resident 1 during meals. During a telephone interview on 7/2/18 at 8:59 a.m., Resident 1's daughter indicated Resident 1 had a caregiver from 8:30 a.m. until 1 p.m. then the daughter would arrive and take over and stay until Resident 1 fell asleep. Resident 1's daughter stated, while Resident 1 was at the facility, the daughter never met with the ST, and was unaware of Resident 1's diagnosis of dysphagia or any diet order changes. The daughter indicated, Resident 1's meals did not come cut up and she would cut the food herself since Resident 1 had difficulty holding her own fork and knife. Resident 1's daughter stated she was not given any training on supervising or cueing Resident 1 during meals, and confirmed that on the day Resident 1 choked and died, there was no cueing or supervision provided to Resident 1 during the meal by facility staff. During a telephone interview on 7/2/18 at 1:29 p.m., Resident 1's private care-giver confirmed she would go to the facility from 8 a.m. until 12 pm or 1 p.m. Resident 1 was able to feed herself but the caregiver would assist in cutting up Resident 1's food since Resident 1 was unable to do this on her own. The caregiver confirmed, Resident 1's meals did not come cut up from the kitchen even though the diet order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on the tray would indicate the meal needed to be cut. The care-giver stated she told the ST she had concerns about the consistency of Resident 1's diet order since she had noticed Resident 1 coughs while eating the regular texture diet. During an interview and concurrent record review on 6/27/18 at 2:55 p.m., the ST indicated, he assessed Resident 1 on 3/22/18 and determined Resident 1 had difficulty chewing and swallowing food. He indicated Resident 1 was admitted with a texture modified diet and he worked with the resident for a week while on that diet order. The ST stated he was concerned about Resident 1 losing weight, since the resident was refusing meals, and started advancing the diet to regular foods but found that Resident 1 needed cueing. The ST indicated after one week he changed the diet texture to regular diet with preference for food to be cut, but did not recall if he trained the daughter or the private caregiver. During an interview on 6/28/18 at 11:24 a.m., the ST indicated Resident 1's diagnosis of dysphagia, oropharyngeal phase meant the resident needed extra time breaking down the food and had difficulty swallowing. The ST indicated he instructed Resident 1 to take smaller bites, chew, tilt her chin down and swallow with a sip of water. However, the ST indicted he had no documentation of training staff or family, nor documentation of Resident 1's refusal of the texture modified diet. During an interview on 6/27/18 at 4:10 p.m., a licensed nurse (LN 1) confirmed, she was the only staff member in the dining room on 4/6/18 at around 5:30 p.m., when Resident 1 started choking on her food. LN 1 indicated she did not remember giving Resident 1 any cueing to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE chew and swallow her food. LN 1 indicated Resident 1 was in the dining room with her daughter. The daughter called LN 1's attention to Resident 1 and told her Resident 1 was choking. LN 1 indicated she proceeded to pat Resident 1 on the back but the resident continued to cough. LN 1 then initiated the Heimlich maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) while Resident 1 was still seated in her chair. LN 1 indicated, she stopped the Heimlich maneuver to move the resident out of the dining room while the resident was actively choking. Resident 1 collapsed while being wheeled in a wheel chair from the dining room into her room. LN 1 stated it was at that time that two Registered Nurses helped her and 911 was called. LN 1 confirmed Resident 1 was pronounced dead at the bedside by the paramedics. During an interview on 6/28/18 at 3:44 p.m., the facility's Minimum Data Set Coordinator (MDSC) indicated the facility did not have any documentation or care plan on the refusal of the Restorative Nursing Assistant (RNA) dining program, or the refusal of the modified texture diet because nursing staff were not aware of those refusals. The MDSC also indicated no care plans were developed for Resident 1's difficulty swallowing or the diagnosis of dysphagia. During an interview on 6/28/18 at 3:51 p.m., the Director of Nursing (DON) stated the normal process at the facility would be for the ST to refer the resident to the RNA dining program so that the RNA's can closely supervise and cue the resident during meals. The DON confirmed there was no referral for Resident 1 to the RNA program or any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555876 (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALTA HEALTHCARE CENTER OF CAMARILLO 6000 Santa Rosa Rd Camarillo, CA 93012 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documentation on the refusal of the RNA program or texture modified diet. The DON also indicated no training was provided to the staff on cueing Resident 1 during meals. During an interview on 6/24/18 at 4:17 p.m., the director of staff development (DSD) indicated no specific training was given by the ST or DSD to the facility staff regarding the assistance and cueing needs of Resident 1 during meals. The facility failed to initiate care plan interventions to address Resident 1's dysphagia (difficulty swallowing) when the resident's diet was changed from texture modified to regular diet on 3/28/18. The facility failed to educate Resident 1's daughter on how to cue and supervise Resident 1 during meals. The facility further failed to provide Resident 1 with supervision and cueing on safe swallowing during dinner on 4/6/18. As a result of these failures, Resident 1 choked and died at the facility on 4/6/18 while eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2HJQ11 Facility ID: CA0500001383 If continuation sheet 8 of 8