Health inspection·October 25, 2024

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 abbreviated standard survey for the investigation of a facility reported incident (FRI). Facility Reported Incident # CA00899866 – Substantiated Representing the Department: 43019 HFEN The inspection was limited to the investigation of a facility reported incident and does not reflect the findings of a full inspection of the facility.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(b)(5)(i)(A)(B)(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for 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: XI7511 Facility ID: CA0500001383 If continuation sheet 1 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to report to the State Agency (Department) and the Ombudsman in a timely manner when injuries/abrasions of unknown origin were noted on Resident 1. This failure had the potential to result in further harm to the resident and to other residents. Findings: On 5/14/24 the facility submitted a report to the Department regarding an injury of unknown origin for Resident 1. The facility's investigation indicated, "On Thursday morning 5/8/24, Director of Staff Development (DSD) noticed a skin abrasion on (Resident 1) shoulder. DSD checked for documentation and did not see anything reported, so DSD cleaned abrasion with normal saline, placed a bandage on the site, and reported finding during morning clinical meeting ... That same morning ... Director of Nursing (DON) delegated skin check to Treatment Nurse, who noted the 1.5cm x 1cm x 0.1 skin abrasion on right shoulder and also noted skin discoloration developing on chin, measuring 0.2cm x 0.2cm". The facility did not report Resident 1's injuries FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XI7511 Facility ID: CA0500001383 If continuation sheet 2 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 of unknown origin until 5/14/24, six days after the facility claimed it was noted on 5/8/24. During an observation on 5/16/24 at 3:06 p.m. in Resident 1's room, Resident 1 was observed inside the room on the bed, awake, responsive, in and out of sleep, covered with a blanket from neck to lower extremities. Resident 1's bed was in a low position with bilateral floor mattresses folded by the wall. Three family members (FM) were at the bedside visiting. Resident 1 was further observed with reddish, purplish skin discoloration under the chin, the size of a quarter and greenish yellowish skin discoloration on the left cheek. During a phone interview on 5/16/24 at 6:45 p.m. with the Responsible Person (RP), the RP indicated, on 5/9/24 around 9 a.m., the RP and FM1 noted a bandage on the resident's right shoulder. The RP sought out the Administrator (ADM) and asked what happened to (Resident 1) since the RP and the family received no notification of a fall or an incident occurring. Per RP, the ADM stated he is not clinical but will ask the DSD to talk to the RP. The RP indicated on 5/9/24, aside from the right shoulder skin abrasion, Resident 1 was also noted to have skin discoloration/bruise on the chin and on the left cheek and no one from the facility seemed to know what happened or even notice the skin abrasion/discoloration until it was brought to their attention by the RP to the facility staff. During an interview on 5/21/24 at 3:45 p.m. with facility ADM, ADM verbalized the family had notified the facility of skin issues on 5/9/24 and the facility should not have waited until 5/14/24 to report the incident to the Department. ADM stated about the discrepancies on the dates on his report when the injuries of unknown origin were noted, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XI7511 Facility ID: CA0500001383 If continuation sheet 3 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 Admin indicated it was on 5/9/24, when family brought it up to the attention of the facility. During an interview on 5/21/24 at 10:02 a.m. with the ombudsman (OMB), the OMB indicated, the facility informed the OMB regarding the injury of unknown origin for Resident 1 via fax on 5/14/24. During a review of Resident 1's "History & Physical (H&P)," dated 5/9/24, the "H&P" indicated, Resident 1 was admitted to the facility with diagnoses including, Acute Posthemorrhagic anemia (a condition in which a person quickly loses a large volume of blood), Gastrointestinal bleeding (bleeding disorder of the digestive tract), cholelithiasis (stones in the gall bladder), cystitis (swelling of the bladder, Chronic Kidney Disease (kidney damage), encephalopathy (toxins in the brain causing changes), diabetes (uncontrolled sugar level in the blood), unspecified dementia (an impairment on cognition without a specific diagnosis), and hypertension (increase in blood pressure). During a review of the facility's policy and procedure (P&P) titled, "Reporting Suspicious Injury of Unknown Source," dated 11/30/22, the P&P indicated, 2. Any injury of unknown origin will be reported by the facility administrator, or his/her designee to the following persons or agencies within 2 hours either by telephone, email or in writing (SOC 341) after the report is made, if events that caused the allegation involve abuse or result in serious body injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. During the review of the facility's P&P titled, "Abuse Prevention Program," dated 12/2022, the P&P indicated, "POLICY: To promote an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XI7511 Facility ID: CA0500001383 If continuation sheet 4 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment. Type of Abuse: ... 7. Injury of unknown source ... VII. Reporting/Response a. The facility shall report any and all allegation of abuse to the District CDPH (California Department of Public Health), Local Ombudsman and/or Local Law Enforcement, either by phone, email, or facsimile within 2-hour timeframe." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XI7511 Facility ID: CA0500001383 If continuation sheet 5 of 5