Health inspection·March 24, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 35's MDS dated 3/6/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23 at 10:25 a.m. in Resident 41's room, Resident 41 was observed in bed with all four side rails up. Residents Affected - Some During a review of Resident 41's MDS dated, 2/24/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23 at 10:40 a.m. in Resident 59's room, Resident 59 was observed in bed with all four side rails up. During a review of Resident 59's MDS, dated 3/23/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 10:51 a.m., 3/24/23, at 11:31 a.m., and 11:45 a.m., in Resident 8's room, Resident 8 was observed in bed with all four bed side rails up. During an observation on 3/21/23, at 10:15 a.m., 3/22/23 at 10:17 a.m., and 3/24/23, at 11:45 a.m., in Resident 53's room, Resident 53 was observed in bed with all four bed side rails up. During a concurrent interview and record review, on 3/24/23, at 3:24 p.m., with Admin 1, Residents 8 and 53's health records were reviewed. When asked about all four bed side rails being up, when the residents are in bed, Admin 1 verbalized, having all of four bed side rails up is considered a restraint. During a review of Residents 8 and 48's Minimum Data Set (MDS)-Version 3.0 Resident Assessment and Care Screening, dated 1/26/23, and 2/6/23, respectively, the MDSs indicated, Section P -Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 10:41 a.m., in Resident 65's room, Resident 65 was observer laying in bed with all four side rails up. During a review of of Resident 65's MDS,dated 1/16/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 10:46 a.m., in Resident 34's room, Resident 34 was observed laying in bed with all four side rails up. During a review of of Resident 34's MDS, dated 1/23/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 12:25 p.m., in Resident 63's room, Resident 63 was observed sitting up on their left side, and all four bed rails were up. During a review of Resident 63's Physician Order, dated 1/12/23, at 9:10 a.m., the Physician Order indicated, Safety device/upper side rails up, side rails up while patient in bed, for possible involuntary movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 2 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0636 Level of Harm - Minimal harm or potential for actual harm During a review of Resident's 63's MDS, dated 1/6/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 10:31 a.m., in Resident 43's room, Resident 43 was observed sitting up on their left side, and all four side rails were up. Residents Affected - Some During a review of Resident 43's MDS, dated 1/6/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 03/21/23, at 03:22 p.m., in Resident 71's room, Resident 71 was observed sitting in bed with three of four bed siderails up. During a review of Resident 71's active order profile, the profile indicated, no orders for side rails to be up. During a review of the Resident 71's admission MDS, dated 2/10/23, the MDS indicated, section PPhysical Restraints for bed rails, was coded zero. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 3 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a computerized assessment tool),was correctly coded for one of 18 sampled residents, (Resident 71), when the resident was reported to be taking insulin (hormone to lower glucose [sugar] in the blood) injections with no diagnosis with diabetes (a disease when your body does not make enough insulin) and not taking insulin. Residents Affected - Few This failure resulted in the facility reporting inaccurate data on Resident 71 on medical status. Findings: During a review of Resident 71's health record, the record indicated, Resident 71 is a [AGE] year-old, with an admitting diagnosis of left Hip Nailing (surgery to repair a broken bone and keep it stable) after a fall. During an interview on 03/21/23, at 03:22 p.m., with Resident 71, Resident 71 verbalized, not diagnosed with diabetes and does not take insulin. During a concurrent interview and record review, on 03/22/23, at 11:00 a.m., with MDS Coordinator (MDS 1), Resident 71's medication orders, dated 02/06/23, MAR dated 3/21/23, and MDS dated 2/10/23 were reviewed. The medication orders indicated, no order for insulin, the MAR indicated, no insulin was given, the admitting MDS, indicated,in part . A. Insulin injections- Record the number of days that insulin injections were received in the last 7 days or since admission. The MDS indicated, 4 days. MD'S 1 acknowledged, Resident 71 was not ordered and not receiving insulin, and stated, Yes that is a mistake, I will correct that right away. During a review the facilities policy and procedure (P&P) titled, Assessment Instrument, Resident/Patient, revised 7/98, the P&P indicated, Purpose: To produce a comprehensive, accurate, standardized, reproducible assessment of each resident's/patient's functional capacity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 4 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 3. During a concurrent interview and record review, on 3/24/23, at 09:39 a.m., with the Informatics Registered Nurse (IRN), Resident 48's Care Plan for ADL Function and Rehab and ADL Flowsheet, dated 3/19/23 through 3/23/23, were reviewed. The care plan indicated, in part .resident requires total assist with ADL's .outcome: resident provided total ADL care .interventions: provide assistance to support level of need .explain all procedures and purpose as needed . turn and reposition at least every two hours. The ADL flowsheet under category of positioning, was missing documentation of turning the resident. The documentation indicated head of bed (HOB) was elevated, but, was missing position changes on 3/13/23 through 3/23/23, for day shift and night shifts. IRN acknowledged Resident 48's ADL care plan indicated to turn and reposition resident every two hours. IRN acknowledged, the documentation was missing on these days and was inconsistent. IRN verbalized if there is no documentation then there is no evidence the turning was done. IRN further acknowledged, Resident 48's care plan was not followed. 4. a.) During an interview on 3/21/23, 10:45 a.m., with Resident 4, Resident 4 verbalized, having wounds on their left hip bone and back. Resident 4 verbalized, for the most part wound care, dressing changes, and position changes are done if the facility is not short staffed. During a concurrent interview and record review, on 3/24/23, at 10:19 a.m., with the IRN, Resident 4's Care Plan for Skin Integrity, updated 6/4/22 and ADL Flowsheet, dated 3/19/23 through 3/23/23, were reviewed. The care plan indicated, in part .resident has chronic left hip abscess . outcome: skin integrity maintained .pressure ulcer will show signs of healing .skin integrity intact .interventions: dressing change per orders .reduce friction and shear . turn and reposition at least every two hours. The ADL flowsheet under category of positioning, was missing documentation of turning the resident. The documentation indicated head of bed (HOB) was elevated, but was missing position changes on 3/13/23 through 3/23/23, for day shift and night shifts. IRN acknowledged, Resident 4's Care Plan for skin Integrity indicated to turn and reposition resident every two hours. IRN acknowledged, the documentation was missing on these days and was inconsistent. IRN verbalized, if there is no documentation then there is no evidence the turning was done. IRN further acknowledged, Resident 4's care plan was not followed. 4. b.) During a concurrent interview and record review on 3/23/23, at 3:31 p.m., with the Registered Nurse (RN 1), Resident 25's Care Plan for Skin Integrity, updated 11/22/22 and ADL Flowsheet, dated 3/19/23 through 3/23/23 were reviewed. The care plan indicated, in part .resident at risk for further skin breakdown due to immobility, admitted with pressure injury . outcome: skin integrity maintained .skin integrity intact .interventions: reduce friction and shear . turn and reposition at least every two hours. The ADL flowsheet indicated, under category of positioning, was missing documentation of turning the resident. The documentation indicated, head of bed (HOB) was elevated, but was missing position changes on 3/13/23 through 3/23/23, for day shift and night shifts. RN 1 acknowledged, Resident 25's care plan indicated to turn and reposition resident every two hours. RN 1 acknowledged, the documentation was missing on these days and was inconsistent. RN 1 verbalized, if there is no documentation then there is no evidence the turning was done. RN 1 further acknowledged, Resident 25's care plan was not followed. During an interview on 3/24/23, at 3:24 p.m., with the Administrator (Admin 1) and the Nursing Supervisor (NSUP), Admin 1 and NSUP both verbalized, turning and positioning the resident should be documented in the medical record every two hours and further verbalized, if not documented then not done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 5 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. During a review of the facility's P&P titled, Care Plans, Resident/Patient-Subacute Care, reviewed 8/20, the P&P indicated, in part . Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired, and the approach to achieve these goals within an acceptable timeframe .Procedure: A. Gather information about the resident/patient .1. Resident assessment .2. Resident/patient history from chart and/or from resident/patient, family and past care givers .3. Physician orders .4. MDS Resident Assessment Forms .F. Update resident/patient care plan where there is a change in the resident's/patient's condition, or when a goal has been reached, or when a review date has been met, or when an approach is ineffective and needs to be changed .update the care plan when a goal has to be revised .date/initial updates and reviews . During an observation on 3/21/23, at 2:49 p.m., in Resident 48's room, Resident 48 was observed sitting up in bed, without any SCDs on the lower legs. During a concurrent observation and interview, on 3/22/23, at 11:00 a.m., with Licensed Vocational Nurse (LVN 2), in Resident 48's room, Resident 48 was observed lying in bed without any SCD's on the lower legs. LVN 2 acknowledged, Resident 48 was not wearing any SCDs and further verbalized, Resident 48 refuses to wear them. During a concurrent interview and record review, on 3/22/23, at 11:05 a.m., with Registered Nurse (RN 3) and RN 4, Resident 48's Physician Orders,dated 1/6/22, Devices Flowsheet, dated 3/13/23 through 3/23/23, and Care Plans were reviewed. The Physician Orders, indicated, Resident 48 was to wear SCDs to both extremities, while in bed for circulation, and to check skin integrity. The Devices Flowsheet indicated, documentation that Resident 48 refused to wear the SCDs. The care plan indicated, no plan for Resident 48's refusal to wear SCDs. RN 3 and RN 4 acknowledged, the physician orders indicated Resident 48 was to wear SCDs to both extremities, while in bed for circulation. RN 3 and RN 4 acknowledged, the Devices Flowsheet had documentation that Resident 48 refused to wear his SCDs. When asked about what you as nurses do when Resident 48 refuses to wear SCD's, RN 3 verbalized, we could call the physician for any new orders or care interventions and initiate a refusal care plan for not wearing the SCDs. RN 3 and RN 4 reviewed Resident 48's Care Plans, and could not find any care plans for SCD refusal. RN3 further verbalized, a refusal care plan for SCDs should have been initiated and implemented. Based on observation, interview and record review, the facility failed to initiate and implement care plans for six out of 18 residents when: 1. Resident 35's care plan for position and mobility was not implemented. 2. Resident 35' has no careplan for the use of the medication Doxycline (an antibiotic/medication used to treat infections). 3. Resident 48's care plan for position and mobility was not implemented. 4. a.) Resident 4's care plan for pressure ulcer was not implemented. b.) Resident 25's care plan for pressure ulcer was not implemented. 5. Resident 48's care plan for refusal of SCDs (sequential compression device- wraps placed around the patient's lower legs in order to decrease the chance of blood clot formation) was not initiated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 6 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0656 6. Resident 8's and Resident 53's care plan for position and mobility was not implemented. Level of Harm - Minimal harm or potential for actual harm These facility failures had the potential for health complications due to developing pressure sores for not documenting resident's position, pressure sore worsening when care plan interventions are not implemented, potential blood clot formation for refusing SCDs, and risk for resident not receiving correct respiratory care. Residents Affected - Some Findings: During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, reviewed 8/20, the P&P indicated, in part . Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired, and the approach to achieve these goals within an acceptable timeframe .Procedure: A. Gather information about the resident/patient .1. Resident assessment .2. Resident/patient history from chart and/or from resident/patient, family and past care givers .3. Physician orders .4. MDS Resident Assessment Forms .B. Identify resident/patient problems based on the above information .identify needs, weaknesses and strengths .C. Establish goals for resident/patient .long-term goals must be re-evaluated quarterly .short-term goals as specified when goal is established .goals must be specific and measurable .indicate a definite date for a goal to be met .goals must be realistic for the resident/patient . 1. During a concurrent interview and record review on 3/23/23, at 3:45 p.m., with the Registered Nurse (RN 4), Resident 35's health record was reviewed. The records indicated, Resident 35 had a care plan for impaired skin integrity, with an intervention to turn and reposition at least every 2 hours. The record further indicated, staff documented positioning of Resident 35, as the head of bed up, without indicating if Resident 35 was on their left, or right side, or flat on the back, multiple times. RN 4 acknowledged, staff should indicate where the resident is facing when repositioning. 2. During a concurrent interview and record review, on 3/23/23, at 3:47 p.m., with RN 4, Resident 35's health record was reviewed. The record indicated, Resident 35 was prescribed Doxycline 100 miligrams tablet, twice a day. No care plan for the antibiotic was located in Resident 35's health record. RN 4 acknowledged, there was no care plan for Doxycycline at the time the order was implemented. 6. During a review of the facility's P&P titled, Care Plans, Resident/Patient-Subacute Care, last reviewed 8/20, the P&P indicated in part . Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired and the approach to achieve these goals within an acceptable time frame. Policy: All residents/patients will have a completed care plan within seven days of admission . Procedure: Identify needs, weaknesses and strengths. Establish the approach that will be used to accomplish the goals for the resident/patient. During a concurrent interview and record review, on 3/24/23, at 10:01 a.m., with IRN, Resident 53's care plan, dated 2/5/23, and Resident 8's care plan, dated 1/24/23, and flow sheets were reviewed. The care plans indicated, turn and reposition at lease every 2 hours. Resident 53's and Resident 8's flow sheet indicted, position is not changed every 2 hours. IRN stated, the reposition every 2 hours should be documented and is not. During a concurrent interview and record review, on 3/24/23, at 3:24 p.m., with Admin 1 and NSUP, Admin 1 and NSUP verbalized, turning and positioning should be documented in the medical record every 2 hours, if not documented, then not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 7 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for two out of 18 sampled residents (Resident 4 and Resident 48) when: Residents Affected - Few 1. Resident 4's Restorative Nursing Assistant (RNA) services were not done five times a week. 2. Resident 4's wound care treatments were not done twice a day. 3. Resident 48's tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, a tube is placed in the hole so a patient can breathe) care treatments were not getting done once a shift. 4. Resident 48 was not wearing an air boot (device to keep pressure off heels when residents spend time in bed). 5. Resident 48's infusion rate, for the water flush, did not match the physician's order. These facility failures had the potential to not meet Resident 4 and 48's care needs by affecting position and mobility, wound healing, skin integrity, respiratory care, and hydration. Findings: During a review of Potter & [NAME] Fundamental of Nursing, 7th Edition, page 336, indicated, in part . The physician is responsible for directing medical treatment .nurses follow physicians' orders unless they believe the orders are in error or harm clients .therefore you need to assess all orders, and if you find one to be erroneous, or harmful, further clarification from the physician is necessary. 1. During a concurrent interview and record review, on 3/24/23, at 10:52 a.m., with the Informatics Registered Nurse (IRN), Resident 4's Physician Orders and Restorative Activity (RNA) Flowsheet, dated 3/20/23 through 3/24/23 were reviewed. The Physician Orders indicated, passive range of motion to bilateral (both) lower extremities five times a week and active range of motion to bilateral upper extremities five times a week. The RNA flowsheet indicated, Resident 4 did not receive RNA services on 3/22/23, 3/23/23, or 3/24/23. IRN acknowledged, the physician orders for RNA five times a week were not being followed. IRN acknowledged, RNA services were missing and not documented on 3/22/23, 3/23/23, and 3/24/23. IRN verbalized, if services are not documented, they are not done and should be. IRN further acknowledged, the physician orders for RNA five times a week were not being followed. 2. During a concurrent interview and record review, on 3/24/23, at 10:30 a.m., with the IRN, Resident 4's Physician Orders and Wound Care Flowsheet, dated 3/13/23 through 3/24/23 were reviewed. The Physician Orders indicated, right sacral (lower back and spine) wound with communication to labia (skin folds around vagina opening) and left hip wounds . clean both wounds twice a day with wound cleanser .use 4x4's (square gauze cloth) and wipe both cavities entirely clean of residues .fill both cavity spaces with one sheet of maxsorb AG4 (a wound dressing). The Wound Care Flowsheet indicated, Resident 4 received wound care only once on 3/14/23, 3/15/23, 3/16/23, 3/19/23, 3/20/23, 3/21/23, and 3/22/23; and no wound care on 3/17/23, and 3/18/23. IRN acknowledged, wound care was missing on 3/14/23 through 3/22/23. IRN acknowledged, the wound care is supposed to be twice a day. IRN further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 8 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged, the wound care treatments were inconsistent, and were not following physician orders. IRN verbalized, if services are not documented, they are not done and should be. 3. During a concurrent interview and record review, on 3/24/23, at 10:06 a.m., with the IRN, Resident 48's Physician Orders and Tracheostomy Tube Flowsheet, dated 3/19/23 through 3/24/23 were reviewed. The Physician Orders indicated, tracheostomy care: cleanse with normal saline and cover with 4x4 drain sponge each shift and as needed. The tracheostomy flowsheet indicated, Resident 48 received tracheostomy care once on 3/19/23, 3/20/23, 3/21/23, 3/22/23, and 3/23/23. IRN acknowledged, tracheostomy care was missing on 3/19/23 through 3/23/23. IRN acknowledged, the tracheostomy care is supposed to be done once a shift. IRN further acknowledged, the Resident 48's Tracheostomy care treatments were inconsistent and were not following physician orders. IRN verbalized, if services are not documented, they are not done and should be. 4. During an observation on 3/21/23, at 2:49 p.m., in Resident 48's room, Resident 48 was observed sitting up in bed with no circulation or protective devices on legs. During a concurrent observation and interview, on 3/22/23, at 11:00 a.m., with licensed vocational nurse (LVN 2), LVN 2 observed and acknowledged, Resident 48 in bed, not wearing Prafo air boots (a device worn on the calf and foot used to prevent bedsores from developing on the back of heel). During a concurrent interview and record review, on 3/22/23, at 11:02 a.m., with LVN 2, Resident 48's Physician Orders and Ortho Devices Flowsheet, dated 2/2/22 and 3/13/23 through 3/24/23 were reviewed. The Physician Orders, dated 2/2/22, indicated, .Air Boot every shift (12 hours) bilateral Prafo Boots for protection. The 'Physician Orders, dated 3/13/23 through 3/24/23 indicated, . Prafo boots to bilateral (both) lower extremities for protection. LVN 2 acknowledged, Resident 48 should be wearing the air boots per physician orders. LVN 2 verbalized there was no documentation of Resident 48 wearing the air boots and acknowledged the orders were not being followed. 5. During an observation on 3/21/23, at 2:46 p.m., in Resident 48's room, Resident 48 was observed sitting up in bed at 45-degree angle. Resident 48 was observed to have a feeding tube with the tube feeding formula, on an infusion pump, infusing at 45 ml/hr (milliliters per hour). Resident 48 was observed to have continuous feeding tube water flush, also running on the infusion pump, at 32 ml/hr. During a concurrent interview and record review, on 3/22/23, at 11:05 a.m., with registered nurses (RN 3 and RN 4), Resident 48's Physician Orders, for GI Flush, dated 7/3/22, were reviewed. The Physician Orders indicated, .GI (gastrointestinal) Flush: 350 ml of water each shift (8 hrs) through feeding tube, which calculates to 43.75 ml/hr. When informed of observing Resident 48's water flush infusing at a rate of 32 ml/hr, RN 3 and RN 4 verbalized, the water flush for 350 ml per shift should be over a 12-hour shift. When reviewing the order, RN 3 and RN 4 acknowledged, the order indicated, to infuse the 350 ml water flush in an 8-hour shift. When calculating 350 ml of water flush, for an 8-hour shift, the infusion rate comes out to 43.75 ml/hr. RN 3 and RN 4 verbalized, the order may be incorrect and would have to confirm with the Registered Dietician (RD 1). RN 3 and RN 4 verbalized, RD 1 informs the physician of an adequate water flush in order to provide the resident with enough hydration. RN 3 and RN 4 further acknowledged, the physician orders were not followed. During a concurrent interview and record review, on 3/22/23, at 10:49 a.m., with RD 1, Resident 48's Physician Orders, dated 7/3/22, for GI Flush were reviewed. RD 1 acknowledged, the GI Flush infusion of 350 ml in an 8-hour shift, did not match the rate of 32 ml/hr, RD 1 verbalized, the infusion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 9 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0658 rate would be at 43.75 ml/hr. RD 1 acknowledged, there was a discrepancy with the GI Flush infusion orders. RD 1 verbalized, the GI Flush order should have said, infuse 350 ml water flush in a 12-hour shift. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 10 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain safe food storage practices when food was available for use past the facility's use by date (a date determined by the facility to dispose of opened food items). This failure had the potential to result in foodborne illnesses. Findings: During a concurrent observation and interview, on 3/21/03, at 9:34 a.m., with Nutrition Services Product Manager (NSPM), and Quality Manager (QM), in the kitchen, the following opened, partially used food items were found, available for use, past their use by date: 1 bag feta cheese, use by 3/10/23 1 bag parmesan cheese, use by 3/12/23 1 bag swiss cheese, use by 3/13/23 1 bag monterey jack cheese, use by 3/13/23 1 bag corn tortillas, use by 3/17/23 1 jar dijon mustard, use by 3/2/23 1 bag corned beef, use by 11/27/22 1 bag corned beef, use by 10/26/22 1 container of matzo ball, use by 1/1/23 1 bag cabbage, use by 3/9/23 1 container peeled potatoes, use by 3/16/23 1 bottle balsamic vinegar, use by 3/2/23 1 bottle rice vinegar, use by 10/13/22 1 container baking powder, use by 10/29/22 The NSPM and QM both agreed, these food items should be discarded and not available for use. During a record review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services (FNS): Floor and Pantry Inventory Management, dated September 19, 2018, the P&P indicated in part, . Outdated pantry stock is removed and discarded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 11 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0812 During a record review of the document titled, Food Storage Chart, undated, the document indicated, in part . Expiration dates printed by the manufacturer apply until the product is opened. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 12 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. During a review of Resident 1's Facility Verification of Informed Consent For Restraints, dated 2/3/23, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails. The consent does not indicate how many side rails (2 or 4). The consent further indicated, the Exhibited Behaviors section was left blank and the signature of Resident/Representative Informed was left blank. b.) During a review of Resident 327's Order Sheet, dated 3/25/22, the Order Sheet indicated, . safety device/upper side rails up. Side rails up while patient in bed, for possible involuntary movement q shift. There was no consent on record. Based on observation, interview, and record review, the facility failed to ensure their policy and procedure for restraints use was followed for 14 of 18 sampled residents (Residents 63, 43, 8, 53, 1, 48, 25, 4, 35, 41, 34, 65 and 59) for the use siderails were with incomplete consents and no consent for siderail use on Resident 327. This facility failure placed residents at risk for being restrained with no proper and complete consents. Findings: During a review of the facility's policy and procedure (P&P) titled, Safety And Physical Restraints; Patient/Resident, last reviewed 8/20, the P&P indicated in part . The purpose is to control a patient's/resident's physical activity by seclusion or mechanical devices in order to protect the patient/resident or others from injury .Physical Restraint: Any manual, physical or mechanical device, or equipment attached or adjacent to the resident's/resident's body that the patient/resident cannot remove easily which restricts freedom of movement or normal access to his body .examples of physical restraints include: .bedside rails used to keep a patient/resident from voluntarily getting out of bed .Involuntary Immobilization: the use of physical restraint when the following behavior is validated, confused or disoriented to the degree that the patient/resident is not responsible for actions and may accidentally or purposely harm himself/herself or others .Procedure: 11. The patient/resident has the right to refuse treatments and restraints .the interdisciplinary team must the discuss reasons for and negative outcomes of restraints with the patient/resident .NOTE: an informed consent for restraints must be signed by the patient/resident and/or by the responsible party .Nursing Interventions: a. verify physician's order for restraint .b. explain to the patient/resident and the family the need for the restraint device and expected care .c. attain signed consent . During an observation on 3/21/23, at 12:25 p.m., in Resident 63's room, Resident 63 was observed sitting up on their left side in bed, and all four bed side rails were up. During a review of Resident 63's Physician Order, dated 1/12/23, at 9:10 a.m., the Physician Order indicated, Safety device/upper side rails up .side rails up while patient in bed, for possible involuntary movement. During a review of Resident's 63's Minimum Data Set (MDS)-Version 3.0 Resident Assessment and Care Screening, dated 1/6/23, the MDS indicated, in section P- Physical Restraints for bed rails was coded zero (not used). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 13 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 63's Informed Consent for Restraints, dated 3/24/23, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails. The consent does not indicate how many side rails (2 or 4), and the Exhibit behaviors section was left blank. The consent further indicated, the signature of the physician obtaining consent; the authorization for restraints given by the Interdisciplinary Treatment Team (IDT) section were left blank, and not signed by an IDT representative. b.) During an observation on 3/21/23, at 10:31 a.m., in Resident 43's room, Resident 43 was observed sitting up on their left side in bed, and all four bed side rails were up. During a review of Resident 43's Physician Order, dated 12/21/22, at 18:42 a.m., the Physician Order indicated, Safety device/upper side rails up .for immobility and involuntary movement/seizure. During a review of Resident's 43's MDS, dated 1/6/23, the MDS indicated, in section P- Physical Restraints for bed rails was coded zero. During a review of Resident 43's Informed Consent for Restraints, dated 1/28/21, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails. The consent does not indicate how many side rails (2 or 4). The Exhibit behaviors section was left blank. The consent further indicated, the authorization for restraints given by the IDT section was left blank, and not signed by an IDT representative.During an observation on 3/21/23, at 10:41 a.m., in Resident 65's room, Resident 65 was observed laying in bed with all four bed side rails up. During a review of Resident 65's Informed Consent For Restraints,dated 1/19/23, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: bilateral side rails. The consent does not indicate how many side rails (2 or 4). The consent further indicated, the Diagnosis section and the Exhibited Behaviors sections are left blank. b.) During an observation on 3/21/23, at 10:46 a.m., in Resident 34's room, Resident 34 was observed laying in bed with all four bed side rails up. During a review of Resident 34's Informed Consent For Restraints, dated 11/4/21, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails. The consent does not indicate how many side rails (2 or 4). The consent further indicated, the Diagnosis section and the Exhibited Behaviors section is left blank. The authorization for restraints given by the IDT section was not signed or dated by an IDT representative. During an interview on 3/24/23, at 3:24 p.m., with the Administrator (Admin 1), Admin 1 was asked about all four bed side rails being up, when the residents are in bed, Admin 1 verbalized, having all of four bed side rails up is considered a restraint, and further verbalized, there should be an informed consent for restraints, when all four bed side rails are up. Admin 1 further verbalized, the informed consent form needs to be completely filled out. Admin 1 verbalized, IDT meetings are held in regards to restraints and the informed consents should be signed. During an observation on 3/21/23, at 10:51 a.m., in Resident 8's room, Resident 8 was observed in the bed and all four bed side rails were up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 14 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/21/23, at 11:30 a.m., with Registered Nurse (RN 2), RN 2 verbalized, our residents should have four bed side rails up for seizure precautions and they should have informed consents. During an observation on 3/24/23, at 11:45 a.m., in Resident 8's room, Resident 8 was observed in bed and all four bed side rails were up. During a review of Resident 8's Informed Consent for Restraints, dated 1/23/23, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails. The consent does not indicate how many side rails (2 or 4). The Diagnosis and Exhibit behaviors sections were left blank. The consent further indicated, the physician signature and authorization for restraints given by the IDT sections were left blank, and IDT section was not signed by an IDT representative. b.) During an observation on 3/21/23, at 10:15 a.m., in Resident 53's room, Resident 53 was observed in bed and all four bed side rails were up. During an interview on 3/21/23, at 11:30 a.m., with Registered Nurse (RN 2), RN 2 verbalized, our residents should have four bed side rails up for seizure precautions and they should have informed consents. During an observation on 3/22/23, at 10:17 a.m., in Resident 53's room, Resident 53 was observed in bed and all four side rails were up. During an observation on 3/24/23, at 11:45 a.m., in Resident 53's room, Resident 53 was observed in bed and all four side rails were up. During a review of Resident 53's Informed Consent for Restraints, dated 2/5/23, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: both side rails up. The consent does not indicate how many side rails (2 or 4), the Diagnosis section was left blank, and the representative did not sign. The consent further indicated, the physician signed the informed consent form, but did not date it; the authorization for restraints given by the IDT section was left blank, and not signed by an IDT representative. During an observation on 3/21/23, at 10:18 a.m., in Resident 35's room, Resident 35 was observed in bed with all four bed side rails up. During a review of Resident 35's health records, the records indicated, Resident 35 does not have a physician's order for side rails. During a review of Resident 35's side rail consent, the consent indicated, the form does not have a diagnosis and no signature for the IDT. b.) During an observation on 3/21/23, at 10:25 a.m., in Resident 41's room, Resident 41 was observed in bed with all four bed side rails up. During a review of Resident 41's health record, the record indicated, an order for two side rails up, only. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 15 of 16 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 555223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. John's Hospital Camarillo D/P Snf 2309 Antonio Avenue Camarillo, CA 93010 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 35's side rail consent, the consent indicated, the form does not have a diagnosis and no exhibited behavior. c.) During an observation on 3/21/23, at 10:40 a.m., in Resident 59's room, Resident 41 was observed in bed with all four bed side rails up. Residents Affected - Some During review of Resident 59's health record, the record indicated order for side rails is for 2 side rails up only. During a review of Resident 59's side rail consent, the consent indicated, the form does not have a diagnosis and no signature for the IDT.During an observation on 3/21/23, at 10:44 a.m., in Resident 4's room, Resident 4 was observed sitting up in bed and all four bed side rails were up. During an interview on 3/21/23, at 11:30 a.m., with Registered Nurse (RN 2), RN 2 verbalized, our residents should have four bed side rails up for seizure precautions and further verbalized should have informed consents. During a review of Resident 4's Informed Consent for Restraints, dated 9/7/18, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails. The consent does not indicate how many side rails (2 or 4). The consent further indicated, the authorization for restraints given by the IDT section was left blank, and not signed by an IDT representative. b.) During an observation on 3/21/23, at 11:20 a.m., in Resident 25's room, Resident 25 was observed sitting up with left tilt, in bed, and all four bed side rails were up. During a review of Resident 25's Informed Consent for Restraints, dated 9/7/18, the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: bilateral side rails. The consent does not indicate how many side rails (2 or 4). The consent further indicated, the Diagnosis section was left blank. The Exhibit behaviors section was left blank. The physician signed the informed consent form but did not date it. (c) During an observation on 3/21/23, at 2:50 p.m., in Resident 48's room, Resident 48 was observed sitting up in bed, and all four bed side rails were up. During a review of Resident 48's Informed Consent for Restraints, dated 1/5/22,the consent indicated, . obtained informed consent from the resident or surrogate decision maker for the use of the following restraints: side rails x 4. The Exhibit behaviors section was left blank. The consent further indicated, the authorization for restraints given by the IDT section was left blank, and not signed by an IDT representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 16 of 16