Health inspection·March 7, 2024

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 interview and record review, the facility failed to ensure one of one sampled resident (Resident 72) had an accurate Minimum Data Set ((MDS) a standardized assessment tool designed to identify potential problems). Residents Affected - Few This failure resulted in Resident 72 not having a care plan ((CP) a tool that outlines the interventions (actions) to be taken to meet the resident's needs) developed for their discharge goal of returning home. Findings: During a review of Resident 72's admission MDS, Section Q, dated 11/14/23, the MDS indicated, neither Resident 72 nor his spouse participated in the assessment and Resident 72's goal was to remain in the facility. During a review of Resident 72's Resident Care Team Meeting, Social Work Review (CTM), dated 11/16/23 at 11:30 a.m., the CTM indicated, Patient is a [AGE] year old, English speaking married male. Patient was transferred from [hospital name] on 11/08/2023 for deconditioning [decreased strength and/or balance] due to sepsis [the body's extreme response to an infection], osteomyelitis [inflammation of bone] left hip . The patient is looking forward to returning home . Prior to being admitted he was independent with ADL's [activities of daily living such as dressing, bathing, ambulating] and was driving, he did not use any DME's [durable medical equipment such as walker, wheel chair, cane] . Social Worker will provide counseling as appropriate to patient and family, encourage participation in IDT to help family reflect on progress and needs, and provide community resources and referrals as needed. During a concurrent interview and record review on 3/7/24 at 10:05 a.m. with a licensed nurse (MDS-C), Resident 72's MDS dated [DATE] and CTM dated 11/16/23 were reviewed. MDS-C stated the MDS and CTM Don't match. MDS-C further stated there was no discharge care plan for Resident 72 and there should have been one. MDS-C additionally agreed if the MDS accurately reflected Resident 72's discharge goal of wanting to return home then it would have triggered the care plan to be developed. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, dated 8/20, the P&P indicated, 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. According to Fundamentals of Nursing ([NAME] et al.; Elsevier: 2017, p. 66), The long-term care setting includes skilled nursing facilities . Individual state regulations, TJC [The Joint Commission], and The CMS [Centers for Medicare and Medicaid Services] govern documentation requirements in these facilities. The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. Compliance with state and federal requirements and reimbursement for care provided in a long-term care facility depend on accurate completion of the required documentation to justify the care provided . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 2 of 11 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 03/07/2024 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review the facility failed to develop individualized care plans for 2 of 18 sampled residents (Residents 34 and 63): Residents Affected - Few 1. For Resident 34, the facility failed to develop an individualized care plan that reflected specific target weight range with measurable goals and timeframe's, and failed to update and revise the care plan when there were changes to the tube feeding (providing nutrition through a tube to the stomach) order. 2. For Resident 63, the facility failed to develop an individualized care plan for a resident with a urinary catheter. This failure resulted in lack of individualized care plans that reflected specific care and measurable goals which impedes the IDT (interdisciplinary team) from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure care needs would not go unrecognized and unmet. Findings: 1. During an observation on 3/4/23 at 12:50 p.m. in Resident 34's room, Resident 34's tube feeding pump was observed to be providing Glucerna (formula to provide nutrition and help manage blood sugar) 1.2 calories per milliliter (a metric unit to measure capacity) at 60 milliliter per hour for 22 hours a day. During a concurrent interview and record review on 3/5/24 at 10:11 a.m. with Patient Services Manager(PSM)/ Registered Dietitian (RD), Resident 34's Nutrition Services Assessment (NSA), dated 1/10/2024, was reviewed. The NSA indicated, Ideal Body Weight: 79.52 kg (kilograms which is = to 175 pounds [lbs]), IBW (ideal body weight) range, 160 - 196 lbs. The NSA documented Resident 34's weight history as: Weights (lb): 3/9/21 - 162, 3/9/22 - 180, 1/11/23 - 197, 2/9/23 - 192, 3/8/23 - 188, 4/18/23 - 194, 5/11/23 - 180, 6/7/23 - 180, 7/5/23 - 172, 8/9/23 - 167, 9/14/23 - 163, 10/4/23 - 160, 11/1/23 - 161, 12/6/23 168, 1/3/24 - 157 lbs .Usual Weight: 73.64 kg (162 lbs). PSM stated Resident 34 previously had an unplanned weight gain, then recently had a planned weight loss to get him back to his usual body weight of 162 lbs. During a concurrent interview and record review on 3/4/23 at 10:35 a.m. with PSM, Resident 34's interdisciplinary (IDT) nutritional status care plan (IDTNCP), last updated on 4/23/23, was reviewed. PSM stated the IDTNCP indicated, Will maintain target weight range. PSM stated the target weight range for Resident 34 was anywhere between 160 - 178 lbs. PSM acknowledged the IDTNCP had not listed Resident 34's individual, specific target weight range on the IDTNCP for clear communication amongst the IDT. PSM stated she would need to find out whose role it was to document on the IDT nutrition care plan. During an interview on 3/5/24 at 11:08 a.m. with Nurse Manager (NM), NM stated it was the MDS [minimum data set] Coordinator role to initiate IDT care plans, and after that nursing can update and revise the care plans as needed. NM reviewed Resident 34's IDTNCP and NM stated he did not know what Resident 34's target weight range was by reviewing the IDTNCP since it was not specific. During a concurrent interview and record review on 3/5/24 at 11:17 a.m. with MDS [minimum data set] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 3 of 11 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 03/07/2024 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 - Few coordinator (MDSC), MDSC stated MDSC was responsible for developing the initial admission baseline care plan. MDSC stated the IDTNCP should be individualized, resident specific and should be updated and revised when there was a change to a tube feeding order. MDSC reviewed Resident 34's IDTNCP, last updated on 4/23/23, and stated she did not know what Resident 34's Will maintain target weight range was as listed on the IDTNCP care plan. MDSC stated she would need to review the RDs notes to find out. Further, MDSC verified Resident IDTNCP was not updated and revised when there were changes to Resident 34's tube feeding order, and should have been. During a review of Resident 34's IDTNCP, last updated on 4/23/23, the IDTNCP indicated, Tube feeding, Ensure rate infusion meets estimated needs, Monitor I/O [input/output], Monitor weight as ordered . During a review of Resident 34's Nutrition Services Brief Note (NSBN), dated 10/11/23, the NSBN indicated, .Pt [patient] continues on Glucerna 1.2 at 50 mL/hr x 22 hrs .kcal [calories] provision below estimated needs, however was appropriate to ameliorate [to make better] previous weight gain. Now clinically significant weight loss is noted at 6 months; - 34 lbs at 6 months (17.5%). Will increase EN by 5 mL and monitor weight trends. Discussed w/family and IDT, who are in agreement with nutrition POC. RDN will continue to monitor. During a review of Resident 34's tube feeding order, dated 10/11/23, the order indicated, Glucerna 1.2, G Tube, 55, x 22 hrs . During a review of Resident 34's tube feeding order, dated 1/10/24, the order indicated, Glucerna 1.2, G Tube, 60, x 22 hrs . During a concurrent interview and record review on 03/06/24 at 11:25 a.m. with NM, NM stated Resident 34's IDTNCP was not updated and revised when there were changes in the tube feeding order, and verified Resident 34's IDTNCP was not individualized to reflect resident was on a planned weight loss after have had an unplanned significant weight gain, and lacked specific target weight range with measurable goals and timeframe's for communication of clear goals amongst the IDT in order to provide effective monitoring of the nutrition plan of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, dated 2/00, the P&P indicated, 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: . Resident's/patient's care plan will include resident/patient problems, projected patient goals, specific approaches for each discipline to accomplish projected goals, review dates and timely updates with change in resident's patient's status ., Procedure: 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 ., D. Establish the approach that will be used to accomplish the goals for the resident/patient. Involve all disciplines. Be specific ., 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 and initial updates and reviews . 2. During a review of the facility's P&P titled, Implementation of the Comprehensive Person-Centered Care Sub-Acute, dated 1/2024, the P&P indicated, (Name of facility) will implement a comprehensive person-centered care plan for each resident that is consistent with resident rights. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 4 of 11 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 03/07/2024 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 - Few comprehensive person-centered care plan will include: The services that are to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being as required. All disciplines will review the care plan and will implement those interventions identified to reach the goals that have been identified by the interdisciplinary team and resident/family. During an observation on 3/5/24, at 10 a.m., Resident 63 had a foley catheter connected by a tubing to a cannister attached to the wall. During a concurrent record review and interview on 3/7/24 at 11:29 a.m. with the Registered Nurse (RN 1), Resident 63's care plan for a urinary incontinence was reviewed. The care plan indicated, urinary incontinence intervention and does not specify the type of intervention for Resident 63's urinary incontinence. RN 1 acknowledged that care plan must be person centered and Resident 63's care plan does not reflect the foley catheter as the intervention for urinary incontinence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 5 of 11 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 03/07/2024 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 72), had a care plan ((CP) a tool that outlines the interventions (actions) to be taken to meet the resident's needs) developed for their discharge goal of returning home. Residents Affected - Few Findings: During a review of Resident 72's admission MDS, Section Q, dated 11/14/23, the MDS indicated, neither Resident 72 nor his spouse participated in the assessment and Resident 72's goal was to remain in the facility. During a review of Resident 72's Resident Care Team Meeting, Social Work Review (CTM), dated 11/16/23 at 11:30 a.m., the CTM indicated, Patient is a [AGE] year old, English speaking married male. Patient was transferred from [hospital name] on 11/08/2023 for deconditioning [decreased strength and/or balance] due to sepsis [the body's extreme response to an infection], osteomyelitis [inflammation of bone] left hip . The patient is looking forward to returning home . Prior to being admitted he was independent with ADL's [activities of daily living such as dressing, bathing, ambulating] and was driving, he did not use any DME's [durable medical equipment such as walker, wheel chair, cane] . Social Worker will provide counseling as appropriate to patient and family, encourage participation in IDT to help family reflect on progress and needs, and provide community resources and referrals as needed. During a concurrent interview and record review on 3/7/24 at 10:05 a.m. with a licensed nurse (MDS-C), Resident 72's MDS dated [DATE] and CTM dated 11/16/23 were reviewed. MDS-C stated the MDS and CTM Don't match. MDS-C further stated there was no discharge care plan for Resident 72 and there should have been one. MDS-C additionally agreed if the MDS accurately reflected Resident 72's discharge goal of wanting to return home then it would have triggered the care plan to be developed. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, dated 8/20, the P&P indicated, 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 6 of 11 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 03/07/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 62), had their head of bed (HOB) elevated to 30 degrees or greater per physician order, due to being on a ventilator by a tracheostomy. Residents Affected - Few This failure had the potential to result in respiratory distress. Findings: During a review of Resident 62's MDS (The Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) which indicated, Resident 62 had diagnoses including, limited range of motion, tracheostomy (surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing) and connected to a ventilator (breathing machine that helps keep your lungs working). During a concurrent observation and interview on 3/4/24 at 4:14 PM with Licensed Nurse 1 (LN 1), in Resident 62's room, Resident 62 was observed with HOB at approximately 10 degrees. LN 1 stated HOB was less than 30 degrees and should be at 30 degrees. During a concurrent interview and record review on 3/6/24 at 2:55 PM with Registered Nurse (RN 2), Resident 62's Physician Order, dated 10/9/23, and Care Plan, dated 10/10/23, were reviewed. The order indicated, Elevate Head of Bed, greater than 30 degrees. The Care Plan indicated, Elevate Head of Bed as Ordered. RN 2 confirmed the HOB should be elevated 30 degrees at all times and at times it wasn't. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 7 of 11 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 03/07/2024 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 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 ensure sanitary conditions within the food service operation when: Residents Affected - Some 1. A nutrition assistant (NA 1) removed dirty gloves after handling dirty dishes, and put on a new pair of gloves, without washing her hands. 2. The high temperature dish machine manufacturer's guidelines were not followed. 3. Posted manufacturer's guidelines for contact time of food service equipment immersed in the sanitizer solution at the three (3) compartment sink was not followed. Failure to ensure proper hand washing and implementing manufacturer's guidelines for cleaning and sanitizing of the dishes had the potential to place five of 70 residents (Residents 52, 58, 61, 1, and 3) who received food from the kitchen at an increased risk of a foodborne illness. Findings: 1. During a concurrent observation and interview on 03/05/24 at 2:31 p.m. with Nutrition Assistant (NA) 2 in the kitchen, in the presence of the Certified Dietary Manager (CDM), NA 2 was wearing gloves while scraping dirty dishes and to move a large garbage bin closer to the high temperature dish machine area. Next, NA 2 was observed to remove her gloves and proceeded to put on a new (clean) pair of gloves that were in a box on the clean side of the high temperature dish machine, without washing her hands. NA 2 stated she did not was her hands after removing her dirty gloves and should have washed her hands prior to putting on a new pair of gloves. CDM verified NA 2 had not washed her hands after removing her dirty gloves, and CDM stated she should have washed her hands prior to putting on a new, clean pair of gloves. During a review of the facility's policy and procedure (P&P) titled, IC [Infection Control]129:FNS [Food & Nutrition Services] Hand Washing, dated 2019, the P&P indicated, 1. Alcohol-based sanitizer can be used when no visible soiling. This is appropriate when staff returns to the department or before or after using gloves. FNS staff must use soap and water when in FNS department .4. Wash hands after smoking, drinking, eating, using bathroom, handling money, soiled glad or dinnerware, garbage, mops, sneezing. 2. During a concurrent observation and interview on 03/05/24 at 2:35 p.m. with NA 1 in the kitchen, in the presence of the Certified Dietary Manager (CDM), NA 1 was observed loading the high temperature (temp) dish machine with dirty dishes from the lunch meal for residents. NA 1 observed the wash water temperature that digitally displayed on the monitor affixed to the outside of the high temp dish machine, and NA 1 stated it was 156 degrees F (Fahrenheit). NA 1 continued to monitor the digital thermometer reading display for the final rinse cycle, and NA 1 stated, the final rinse cycle was over 180 degrees F. NA 1 ran a thermocromatic (property of substances to change color due to a change in temperature) color-change band through the high temp dish machine which was observed to turn orange which was a method to ensure the dishes final rinse cycle reached 180 degrees F for sanitizing the dishes. During a review of the manufacturer's data plate affixed to the high temp dish machine, the data (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 8 of 11 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 03/07/2024 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 plate indicated, Hot Water Sanitizing; Wash Temp 160 degrees F Min [minimum], Final Rinse Temp 180 degrees F Min, 194 degrees Max [maximum]. During a concurrent interview and record review on 3/5/24 at 2:44 p.m. with CDM, the CDM showed a binder that was on a shelf in the dish machine room that contained directions to dietary staff and a monitoring log for the high temp dish machine that was reviewed. The directions indicated, The 'Dish Machine Temperature Log' is used to record the water temperatures of the wash, rinse, and final rinse cycles of the dish machine. You will find the temperatures measured by the machine on the display at the front of the dish machine. All three temperatures (wash, rinse, and final rinse) must be recorded and within range before use. Temperatures must be checked three times a day: before breakfast items are washed, before lunch items are washed, before dinner items are washed. Steps: To record the temperatures from the display, start machine and run for a few minutes before looking at the display. Record the wash, rinse, and final rinse temps noted on the display onto the 'Dish Machine Temperature Log.' Check to see if temps are within the appropriate range as follows: WASH temp must be between 110 degrees F - 140 degrees F, RINSE temp must be between 150 degrees F - 165 degrees F, FINAL RINSE temp must be between 180 degrees F - 200 degrees F .CORRECTIVE ACTION: If temps on the display are out of range, start booster heater and allow machine to run a few minutes. Re-check the display .If temps remain below goal, notify manager and take the equipment out of service. Submit a work order for repair. Wash and sanitize all items in the three-compartment sink until the machine is repaired. CDM reviewed the Dish Machine Temperature Log, dated 3/5/24 for lunch that indicated, wash 129 [degrees F], rinse 157 [degrees F] and final 185 [degrees F] initialed by NA 1. CDM stated the directions to staff located in the binder and the directions located on the dish machine temperature log contained incorrect directions. CDM stated the high temperature dish machine manufacturer's guidelines should have been followed and were not. During a concurrent interview and record review on 3/6/24 at 10:24 a.m. with CDM, Patient Services Manager (PSM) and Director of Nutrition Services (DNS), the high temp dish machine logs from December 2023 to current (3/5/24) were reviewed. CDM stated, the high temp dish machine logs were not correct daily for the logs reviewed. DNS stated it was her role as a Registered Dietitian (RD) to provide frequently scheduled consultation to the CDM to include oversight over system operations within the food service department. DNS stated the facility does conduct monthly QI (quality improvement) inspections within food service operations that included food safety and sanitation. DNS stated the incorrect directions and out of range temperatures recorded daily on the high temp dish machine log, during the review period of December 2023 to current, was missed. During a review of the facility's policy and procedure (P&P) titled, IC [infection control]137: FNS [Food & Nutrition Services] Dish Machine Documentation of Temperatures, dated 2019, the P&P indicated, Steps; 1. Dish machine wash and rinse temps must be maintained based on manufacturer's guidelines. Dish machines depending on model and manufacturer could have different temperature ranges. 2. Start dish machine, run for full cycle. Take temp using thermometer or test strip while running wash cycle. Temperature testing should be done at the start of each meal service wash cycle. 3. Document temperature. Reconcile temperatures out of range. Ensure staff is in-serviced on how to address out-of-range temperatures. 4. Rerun test strip or thermometer through cycle, if temp out of range report to supervisor. 5. Stop using dish machine if out of range. Call for service. Wash dishes in pot sink or use paper products until machine in service . During a review of the FDA (Food & Drug Administration) Food Code Annex (FDAFC), dated 2022, the FDAFC indicated, The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 9 of 11 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 03/07/2024 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 warewashing machine has been tested, and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. (FDA Food Code Annex 3, 4-204.113 Warewashing Machine, Data Plate Operating Specifications.) During a review of the FDAFC, dated 2022, the FDAFC indicated, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. (FDA Food Code Annex 3, 4-501.15 Warewashing Machines) During a review of the facility's job description for Director of Nutrition Services (JDDNS), (undated), the JDDNS indicated, Job Summary: Plans, administers and directs all location activities related to food service including financial accountability, compliance with standards established by the [name of corporation] and regulatory agencies. Leads food and nutrition services departments Has authority and delegated responsibility including, the daily management of the food services, implementing training programs for dietary staff and assuring that established polices and procedures are maintained. 3. During an observation on 3/0/24 at 2:45 p.m. in the kitchen, NA 3 was observed utilizing the three (3) compartment sink to wash cooking equipment used inside the kitchen. NA 3 was observed placing containers from the rinse water into the sanitizer solution in the third compartment of the 3-compartment sink for twenty-five seconds as counted by the second hand located on a large clock on the wall at the 3-compartment sink area. After 25 seconds, NA 3 removed the cooking equipment (containers) from the sanitizer solution and placed them on a rack to air dry to be available for use. During an interview on 3/5/24 at 2:49 p.m. with NA 3, in the presence of the Certified Dietary Manager (CDM), NA 3 stated he was trained to keep the dishes/containers in the sanitizer solution for one minute. NA 3 was asked if he had kept the food containers that he had just removed from the sanitizer compartment in the sanitizer for one minute, and NA 3 stated, No, I was in a hurry. CDM stated the expectation was immersion of dishes/containers in the sanitizer solution of the third compartment of the 3-compartment sink for one minute to effectively sanitize. During a review of a poster labeled with the manufacturer's name of the sanitizer in use, the poster titled, Three Compartment Sink Set-Up, indicated, Sanitize one minute. During a review of the facility's directions to staff located in a binder near the 3-compartment sink, the directions indicated, To manually wash and sanitize equipment and dishes, we use a three-compartment sink method. The first sink is used for washing, the second for rinsing, and the third for sanitizing . During a review of the facility's policy and procedure (P&P) titled, IC [Infection Control] 136: FNS [Food & Nutrition Services] Sanitation Food Contact Surfaces, dated 2019, the P&P indicated, Steps; 1. Sanitizing solutions are used to clean all work areas based on manufacturer recommendation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 10 of 11 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 03/07/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm The facility failed to maintain the infection control program when staff left an unflushed suction catheter (a tube used to clear the airway by removing secretions from the oropharynx with the aid of a rigid suction tip) resulting in secretions dripped on top of the nightstand for one of six residents (Resident 50) with a tracheostomy tube. Residents Affected - Few This failure placed Resident 50 at risk for the spread of healthcare-associated infection. Findings: During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Plan, dated 4/06, the P&P indicated, VI. Prevention Strategies A. The Infection Prevention and Control Program includes prevention strategies, including but not limited to: . 2. Cleaning, disinfection (process to remove microorganisms by liquid chemicals) and sterilization (a process to destroy microorganism with the use of heat, radiation or chemical agent) . 6. Compliance to Infection Prevention and Control Program. During a review of the P&P titled, Use of Closed System Suction Apparatus, dated 6/14, the P&P indicated, Equipment Suction source, 1. wall or portable. 2. Sterile saline for irrigation - 3 cc vials .in part . Procedure 8. Use normal saline vial to flush catheter by initiating suction and then introducing solution slowly . Rationale/Precautions: Normal Saline will clear secretions from catheter. During a review of Resident 50's Physician Progress Notes (PPN), dated 3/24, the PPN indicated, Resident 50 had a diagnosis of Chronic Respiratory Failure and was dependent on tracheostomy (an opening to the trachea to help with breathing). During an observation on 3/4/24 at 11:44 a.m. in the second level nursing floor, there was a drip of clear liquid on top of Resident 50's nightstand just directly above the end of the used suction catheter that was filled with white frothy sputum (mucus). During an interview on 3/4/24 at 11:50 a.m. with Registered Nurse 1 (RN 1), RN 1 verbalized that suction catheters must be flushed with normal saline solution after each use to clear the catheter from secretions. RN 1 further verbalized the table must also be cleansed and disinfected. RN 1 acknowledged the suction catheter was not flushed, and Resident 50's nightstand was not cleaned and disinfected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555223 If continuation sheet Page 11 of 11