Health inspection·July 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure ventilation covers/panels were clean and free of dust when : 1. The ventilation cover and window tracks in room [ROOM NUMBER] was found with thick dust and dirt. 2. The ventilation cover outside room [ROOM NUMBER] was dirty. This failure have the potential for unclean and dirty air from the ventilations to circulate around which could cause respiratory infections inside the facility (residents, staff and visitors ). Findings: 1.During the facility initial tour on 7/11/23 at 10:27 a.m. inside room [ROOM NUMBER], the ventilation cover was observed with thick dust and the window tracks with piled black dirt. During an interview and concurrent observation on 7/13/23 at 9:05 a.m. with the facility Housekeeping Manager (HM), the HM acknowledged the vent cover and windows were dusty and dirty and were not cleaned by the weekend housekeeper. Review of the Centers for Disease Control and Prevention (CDC) website, https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/services.html, accessed on 7/20/23, indicated, Housekeeping Surfaces require cleaning and removal of soil and dust. Dry conditions favor the presence of gram-positive cocci [bacteria capable of causing infections] . in dust and on surfaces . Fungi [organisms capable of causing infections] are also present on dust. 2. During an observation on 07/12/23 at11:25 a.m. outside room [ROOM NUMBER], the ceiling ventilator cover had peeling black caulking and brown circular spots. During an interview and concurrent observation on 7/13/23 at 3:01 p.m. outside room [ROOM NUMBER] with the HM, the HM acknowledged the ventilator cover was dirty. HM stated they do not keep a log to know when the ventilator cover was last cleaned. During a review of the facility's policy and procedure (P&P) titled, Housekeeping, Cleaning Resident's Rooms, dated 5/21, the P&P indicated, It is the policy of this facility to provide a clean, comfortable, homelike, and sanitary living area . High dust/Low dust, Vacuum, Dust mop floors . Spot Page 1 of 8 555770 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

F 0584 clean all mirrors, walls, and windows. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555770 Page 2 of 8 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

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 two of two unsampled residents (Residents 84 and 100) assessements were accurate when : Residents Affected - Few 1.The Minimum Data Set Assessment ((MDS- residents assessement ) Section K (Nutrition) for Resident 84 was not answered accurately and with missing infromation. This failure have the potential for an inaccurate assessment of the resident's nutrional and dietary status which can affect the plan of care . 2. For Resident 100, the Section A (discharge infromation) in the MDS have an inaccurate information. This failure have the potential for inappropriate discharge plans or information that can affect the resident's rights to admission or discharge. Findings: 1. During a review of the facility's Resident Matrix ((RM) used to identify pertinent care categories for: all residents), dated 07/11/2023, the RM indicated Resident 84 was receiving tube feedings (any type of tube that can deliver food/nutritional substances/ fluids/medications directly into the gastrointestinal (stomach) system). During a review of Resident 84's Order Summary Report ((OSR) physician order) dated 07/12/2023, the OSR indicated Enteral (method of feeding that uses a tube placed in the stomach) Feed Order four times a day bolus (all at once) feeding of Peptamen (tube feeding formula) 1.2 (375CC) via G-tube (feeding tube) start date 6/27/23. During a review of Resident 84's MDS, dated [DATE], the MDS indicated, no response at K0510 B, Feeding tube . 2. While a Resident. During a review of Resident 84's MDS, dated [DATE], the MDS indicated no response at K0710 A, Proportion of total calories the resident received through . tube feeding. During a review of Resident 84's MDS, dated [DATE], the MDS indicated no response at K0710 B, Average fluid intake per day by tube feeding. During a concurrent observation and interview on 07/12/23 at 10:34 a.m. in Resident 84's room, Resident 84 showed where his feeding tube was located on his stomach. During an interview on 07/12/2023 at 10:36 a.m. with a licensed nurse (LN 1), LN 1 stated, Resident 84 receives supplement bolus tube feeding at 8am, 12pm, 4pm and 8pm. During a concurrent interview and record review on 07/12/2023 at 10:43 a.m. with the MDS nurse (MDS 1), Resident 84's MDS section K, dated 06/27/2023 was reviewed. MDS 1 stated it should indicate resident has a feeding tube;and Section K needs to be corrected. 555770 Page 3 of 8 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual, page K-11, in section titled, K0510: Nutritional Approaches, dated 10/2019, indicated, Check all nutritional approaches performed after admission/entry or reentry to the facility . Check all that apply . K0510B, feeding tube. 2. According to Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (Centers for Medicare & Medicaid Services, Version 1.17.1, October 2019, p. 2-11), Discharge Assessment . This assessment includes clinical items for quality monitoring as well as discharge tracking information. During a concurrent interview and record review on 7/13/23 at 3:08 p.m. with a MDS 2, Resident 100's MDS section titled, Identification Information, dated 6/12/23 was reviewed. The MDS at A0310F and A0310G indicated, Resident 100's return to the facility was anticipated from an unplanned discharge. MDS2 stated Resident 100 was not anticipated to return to the facility and had a planned discharge home. MDS 2 further stated, I'll see if I can go about correcting this. 555770 Page 4 of 8 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure one of three unsampled residents (Resident 23) had accurate documentation in their medical record. Residents Affected - Few For Resident 23, this failure resulted in an inaccurate representation of a change in their physical condition. Findings: During a review of Resident 23's Progress Note (PN), dated 5/11/23 at 10 a.m., the PN indicated, Resident c/o [complains of] SOB [shortness of breath] . resident with productive cough, bil [both sides] lung wheezing . new orders to send resident to ER . called 911, resident left facility at 1020 with paramedics. During a review of Resident 23's PN, dated 5/11/23 at 1:59 p.m., the PN indicated, No respiratory changes observed. No Respiratory treatments. During an interview on 7/14/23 at 10:11 a.m. with a licensed nurse (LN3), LN3 stated, I wrote the progress note after the resident was discharged . LN 3 also stated, I did the assessment at about eight am and recorded it at one fifty-nine pm. LN3 further stated, There wasn't a way to change the time of the documentation. During a review of the facility's policy and procedure (P&P) titled, Documentation Principles, undated, the P&P indicated, Entries must be . Timely . Late Entry . Include the date/time of the current entry, the date/shift or time the entry should have been made and proceed with the data entry. 555770 Page 5 of 8 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of the facility's policy and procedure titled Utility Room, Soiled and Clean, dated 11/2017, indicates The facility shall provide separation of soiled and contaminated supplies and equipment from theh clean supplies and equipment. Clean vs soiled fields will be clearly identified in Utility Room (floors and countertops). Residents Affected - Some During a concurrent observation and interview on [DATE], at 2:21 p.m., with the Infection Preventionist (IPS) and Central Housekeeping Manager (HM) Utility Room on Station 1, the room was noted to have 2 counters in the room. One counter had a sign denoting clean and the other counter on opposite side of the room had a sign denoting soiled. The IP and HM explained that the room is used for clean and soiled items and the signs are use to guide staff in differentiating areas of the room designated as such. On the counter marked soiled, there was a cardboard box containing unused specimen cups. [NAME] & [NAME] confirmed the box contained clean cups and should not have been placed on the soiled counter top. During an interview on [DATE], at 11:00 a. m., with the DON, the DON acknowledged that placement of clean supplies on the countertop designated as soiled is not acceptable. 3. During a concurrent observation and interview on [DATE], at 2:30 p.m., with , in Utility Room on Station 1, supplies were noted to be stored in the cabinets above both counter tops. Several medical supply items were pulled to check integrity of the packaging and expiration dates. The following items were found to have expired dates: Nasopharyngeal sample collection kit for viruses with an expiration date of 04/2023. Another specimen collection swab was noted to have expiration date of [DATE]. Both the IP and HM confirmed that the dates on the packaging of these supplies were the manufacturer expiration dates. Upon further discussion with the IP and HM related to the process of ensuring expired supplies are removed from use prior to expiration, both indicated there is no consistent process in place to monitor medical supply expirations and there is no facility policy and procedure in place related to monitoring and removal of expired supplies. During an interview of [DATE], at 11:00 a.m., with the DON, the DON acknowledged the above referenced supplies were expired and currently the facility has no written procedure in place to guide the monitoring of and removal of expired supplies from use. 4. During an observation on [DATE], at 12:34 p.m., a warning sign outside room [ROOM NUMBER] indicated, STOP, in red lettering. Under STOP and in yellow, Do not exit room with the protective items (Gloves, Goggles, Gown, Mask, etc). Discard items in the waste basket provided in room. Two white bins located in the hallway outside room [ROOM NUMBER] were labeled, Trash and Gowns and Linens. A contaminated yellow gown discarded in the hallway bin had parts of the contaminated gown hanging outside the bin with residents and staff passing by the uncontained parts of the contaminated gown. During a review of Resident 552's admission Record (AR), dated [DATE], the AR indicated, Resident 552 had the diagnosis including Extended Spectrum Beta Lactamase (ESBL) Resistance [a bacteria resistant to antibiotics] . Resistance to multiple antibiotics. During a review of Resident 552's History & Physical (H&P), dated [DATE], the H&P indicated, ESBL urine Plan: Isolation [to wear PPE when entering Resident 552's room]. 555770 Page 6 of 8 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on [DATE], at 9:55 a.m., in room [ROOM NUMBER], Resident 552 was observed receiving treatment from the Speech Therapist ((ST) healthcare professional that helps people with speech and language problems). ST was observed wearing gloves and a yellow isolation gown while interacting with Resident 552. During further observation, the ST was standing partially outside the room while removing the contaminated yellow isolation gown. ST was next observed to fold the gown, then walk in the hallway wearing the contaminated gloves and discarded the contaminated isolation gown in the contamination bin labeled gowns and linens. ST removed the contaminated gloves in the hallway and discarded them into the contaminated trash bin. During an interview on [DATE], at 10:05 a.m., with the ST, ST stated, I will check and follow the isolation warning sign outside the resident's room prior to entering. The ST read the warning sign for Resident 552, then stated I was not following the instructions for isolation. The bins for trash and gowns were placed outside the room when it should have been inside. During an observation on [DATE] at 10:15 a.m. outside room [ROOM NUMBER], two Certified Nursing Assistant (CNA 1 and CNA 2) were observed to exit isolation room [ROOM NUMBER] wearing contaminated gloves. During an interview on [DATE], at 10:25 a.m., with CNA 1 and CNA 2, CNA 2 stated the used PPEs must be discarded inside the room. CNA 1 stated they were taught during infection control in-services to discard PPEs inside the room. CNA 2 further stated the reason why contaminated PPE is removed inside the room is due to possible contamination with other staffs and residents outside the isolation room. During an interview on [DATE], at 11:30 a.m., with the Infection Preventionist (IP), the IP acknowledged, the staffs must remove the contaminated PPEs inside the isolation room and discard into the bins in the isolation room. The IP further acknowledged, the bins must be inside the isolation room to prevent contamination risk to staff, residents, and visitors. During a review of the facility's policy and procedure (P&P) titled, Infection Control, Technique for Contact Isolation, dated 5/20, the P&P indicated, Donning [putting on] and Doffing [taking off] of PPE will be done following CDC guidelines . No staff can walk in the hallways with PPE on. Review of the Centers for Disease Control and Prevention (CDC) website, https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html, accessed on [DATE], indicated, Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens [disease causing microorganism]. Based on observation, interview, and record review the facility failed to ensure staff were properly following isolation precautions to prevent the spread of disease for two of 10 Sampled residents (Residents 552 and 96) when: 1. Staff member removed their used personal protective equipment (PPE) outside the isolation room ( supposed to be inside prior to exiting ) and did not perform hand hygiene after removing their PPE. 2. Facility policy and procedure related to the separation of clean and soiled items in Utility 555770 Page 7 of 8 555770 07/14/2023 Camarillo Healthcare Center 205 Granada Street Camarillo, CA 93010

F 0880 Rooms was not followed. Level of Harm - Minimal harm or potential for actual harm 3. Expired medical supplies were not identified and removed from medical supply cabinets. 4. Remove contaminated isolation gown before exiting the resident room. Residents Affected - Some These failures had the potential to transmit infectious microorganisms and increase the risk of infection for residents, staff, and visitors. Findings: 1. During an observation on [DATE] at 10:52 a.m., a license nurse (LN 2) was observed removing contaminated (soiled ) PPEs (isolation gowns and gloves)) in the hallway at outside room [ROOM NUMBER],an isolation room, (occupant with infectious condition ) into a waste bin. During an interview on [DATE] at 10:52 a.m. with LN 2, regarding the process of removing and discarding soiled PPEs, LN 2 indicated , the soiled PPEs should have been removed inside room [ROOM NUMBER], and not outside. The waste bin should also be inside the isolation room and not outside. During a concurrent observation and interview on [DATE] at 11:50 a.m. with Infection Preventionist (IP 1), in the hallway outside room [ROOM NUMBER], a staff was observed not performing hand hygiene after removing a used PPE. IP 1 stated, Staff should perform hand hygiene before and after entering isolation rooms. During a review of the facility's policy and procedure (P&P) titled, Infection Control, Technique for Contact Isolation, dated 5/20, the P&P indicated, It is essential to wash hands/and/or use hand disinfectant on entering and leaving room . No staff member can walk in the hallways with PPE on. 555770 Page 8 of 8