Health inspection·December 4, 2024

F 0692 Level of Harm - Minimal harm or potential for actual harm for night shift was 120 cc ' s. The total equaled 970 cc ' s. The 24-hour total intake was documented as 1100 cc ' s. 11/14/24 the intake for day shift was 425 cc ' s, intake for pm shift was 300 cc ' s, and intake for night shift was 120 cc ' s. The total equaled 845 cc ' s. The 24-hour total intake was documented as 1400 cc ' s. Residents Affected - Few 11/15/24 the intake for day shift was 425 cc ' s, intake for pm shift was 500 cc ' s, and intake for night shift was 30 cc ' s. The total equaled 955 cc ' s. The 24-hour total intake was documented as 1400 cc ' s. During a concurrent interview and record review on 1/10/25 at 2:22 p.m., with the director of nursing (DON), Resident 1 ' s Intake Record and the Calculated 24-hours Intake Record dated 11/8/24-11/15/24 were reviewed. When asked if the daily intake record totals should match the 24-hour intake record totals, the DON verbalized yes, the totals should match. The DON acknowledged the daily intake totals did not match the 24-hour intake totals and they should. The DON further acknowledged the intake totals were not accurate. During a review of the facility ' s policy and procedure (P&P) titled, Intake and Output dated 6/11/24, indicated in part . It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance. Intake and output shall be recorded by each shift. During a review of Resident 1 ' s ED Physician Notes dated 11/16/24, indicated in part . Resident 1 was recently diagnosed with pneumonia, on 2 liters of oxygen via nasal cannula coming from skilled nursing facility for shortness of breath .Diagnosis: Sepsis with acute hypoxic (not enough oxygen in the blood) respiratory failure and pneumonia. 2. During a review of Resident 2 ' s Physician Orders dated 9/5/24-11/13/24, the physician orders indicated to record intake each shift and record the total daily intake in ml/cc (milliliters/cubic centimeters) every shift for monitoring due to poor appetite. The physician orders indicated to calculate the 24 hours intake on the night shift. During a review of Resident 2 ' s Nutrition Evaluation dated 9/6/24, indicated in part . meal intake assessment: 0-25%, fluid intake assessment: needs encouragement with fluid intake .IV support: yes .estimated fluid needs not less than 1500 cc/day. During a review of Resident 2 ' s Intake Record and the Calculated 24-hours Intake Record dated 11/1/24-11/13/24, indicated on: 11/1/24 the intake for day shift was 250 cc ' s, intake for pm shift was 120 cc ' s, and intake for night shift was 120 cc ' s. The total equaled 490 cc ' s. The 24-hour total intake was documented as 700 cc ' s. Less than 1500 cc/day. 11/5/24 the intake for day shift was 200 cc ' s, intake for pm shift was 120 cc ' s, and intake for night shift was 60 cc ' s. The total equaled 380 cc ' s. The 24-hour total intake was documented as 560 cc ' s. Less than 1500 cc/day. 11/6/24 the intake for day shift was 400 cc ' s, intake for pm shift was 200 cc ' s, and intake for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555770 If continuation sheet Page 2 of 7 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 555770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camarillo Healthcare Center 205 Granada Street 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few night shift was 120 cc ' s. The total equaled 720 cc ' s. The 24-hour total intake was documented as 750 cc ' s. Less than 1500 cc/day. 11/7/24 the intake for day shift was 200 cc ' s, intake for pm shift was 120 cc ' s, and intake for night shift was 120 cc ' s. The total equaled 440 cc ' s. The 24-hour total intake was documented as 700 cc ' s. Less than 1500 cc/day. 11/9/24 the intake for day shift was 200 cc ' s, intake for pm shift was 120 cc ' s, and intake for night shift was 120 cc ' s. The total equaled 440 cc ' s. The 24-hour total intake was documented as 420 cc ' s. Less than 1500 cc/day. 11/11/24 the intake for day shift was 100 cc ' s, intake for pm shift was 120 cc ' s, and intake for night shift was 120 cc ' s. The total equaled 340 cc ' s. The 24-hour total intake was documented as 600 cc ' s. Less than 1500 cc/day. 11/12/24 the intake for day shift was 100 cc ' s, intake for pm shift was 100 cc ' s, and intake for night shift was 30 cc ' s. The total equaled 230 cc ' s. The 24-hour total intake was documented as 600 cc ' s. Less than 1500 cc/day. During a concurrent interview and record review on 12/4/24 at 11:09 a.m., with the assistant director of nursing (ADON), Resident 2 ' s Intake Record and the Calculated 24-hours Intake Record dated 11/1/24-11/13/24 were reviewed. ADON acknowledged the daily intake totals did not match the 24-hour intake totals and they should. ADON verbalized Resident 2 had an IV (intravenous-in the vein) infusion on 11/3/24 and 11/11/24, the nursing staff did not include the IV fluids infusion as part of the intakes and further verbalized they should have. The ADON further acknowledged the intake totals were not accurate. When asked how you know Resident 2 was receiving adequate fluids and hydration, when the intake totals were not accurate, ADON verbalized you look at other areas as well like lab results (the blood urea nitrogen) and meal intakes. ADON verbalized Resident 2 ' s labs were all normal. When asked about the 24-hour totals not meeting the recommended number of fluids (no less than 1500 cc/day) per the Nutrition Evaluation, ADON verbalized if had concerns that the resident was not getting in enough fluids, could call the physician to increase the IV infusion rate. Further review of Resident 2 ' s medical record had no other documentation that the physician was informed of Resident 2 not meeting the 1500 cc/day of recommended fluid intake. During a review of Resident 2 ' s Lab Results dated 11/11/24, indicated in part .the blood urea nitrogen (BUN- a test to assess how well the kidneys are functioning, a higher-than-normal BUN level can indicate kidney problems, heart failure, dehydration) was elevated at 37 (higher-than-normal). The creatinine (a test to assess how well the kidneys are functioning, a higher-than-normal creatinine level can indicate kidney problems, heart failure, dehydration) was elevated at 1.73 (higher-than-normal). During a concurrent interview and record review on 1/10/25 at 2:00 p.m., with the director of nursing (DON), Resident 2 ' s Intake Record and the Calculated 24-hours Intake Record dated 11/1/24-11/13/24 were reviewed. When asked if the daily intake record totals should match the 24-hour intake record totals, the DON verbalized yes, the totals should match. The DON acknowledged the daily intake totals did not match the 24-hour intake totals and they should. The DON further acknowledged the intake totals were not accurate. During a review of Resident 2 ' s ED Physician Notes dated 11/13/24, indicated in part . Resident 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555770 If continuation sheet Page 3 of 7 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 555770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camarillo Healthcare Center 205 Granada Street 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few presents with altered mental status and failure to thrive .Over the past week, progressive there has been a progressive decline in her condition, including decreased mental status, not eating, and not following her normal routine .Resident 2 typically is able to converse and ambulate with assistance but unresponsive this morning . Diagnosis: Pneumonia, urinary tract infection (UTI), Sepsis and chronic kidney disease. During a review of the facility ' s policy and procedure (P&P) titled, Intake and Output dated 6/11/24, indicated in part . It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance. Intake and output shall be recorded by each shift .the licensed staff will monitor the intake and output daily for timely follow-up and will do weekly evaluation to update MD (physician) if there is a need for continuation .the registered dietician will do the follow-up assessment review for recommendation if indicated . Based on interview and record review the facility failed to: 1. Document fluid intake accurately for 1 out of 2 sampled residents (Resident 1). 2. Document fluid intake accurately for 1 out of 2 sampled residents (Resident 2). This failure had potential to affect the hydration status of Resident 1 and may have contributed to Resident 1 being sent out to the emergency room (ER) for shortness of breath; and admitted to the hospital for sepsis and pneumonia. This failure had potential to affect the hydration status of Resident 2 and may have contributed to Resident 2 being sent out to the ER for altered mental status; and admitted to the hospital for pneumonia, urinary tract infection (UTI) and sepsis. Findings: 1. During a review of Resident 1's Physician Orders dated 11/6/24-11/16/24, the physician orders indicated to record intake each shift and record the total daily intake in ml/cc (milliliters/cubic centimeters). The physician orders indicated to calculate the 24 hours intake on the night shift. During a review of Resident 1's Intake Record and the Calculated 24-hours Intake Record dated 11/8/24-11/15/24, indicated on: 11/9/24 the intake for day shift was 450 cc's, intake for pm shift was 550 cc's, and intake for night shift was 550 cc's. The total equaled 1550 cc's. The 24-hour total intake was documented as 1010 cc's. 11/10/24 the intake for day shift was 500 cc's, intake for pm shift was 360 cc's, and intake for night shift was 120 cc's. The total equaled 980 cc's. The 24-hour total intake was documented as 1590 cc's. 11/11/24 the intake for day shift was 500 cc's, intake for pm shift was 450 cc's, and intake for night shift was 120 cc's. The total equaled 1070 cc's. The 24-hour total intake was documented as 1300 cc's. 11/12/24 the intake for day shift was 450 cc's, intake for pm shift was 450 cc's, and intake for night shift was 120 cc's. The total equaled 1020 cc's. The 24-hour total intake was documented as 1180 cc's. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555770 If continuation sheet Page 4 of 7 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 555770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camarillo Healthcare Center 205 Granada Street 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 0692 Level of Harm - Minimal harm or potential for actual harm 11/13/24 the intake for day shift was 500 cc's, intake for pm shift was 350 cc's, and intake for night shift was 120 cc's. The total equaled 970 cc's. The 24-hour total intake was documented as 1100 cc's. 11/14/24 the intake for day shift was 425 cc's, intake for pm shift was 300 cc's, and intake for night shift was 120 cc's. The total equaled 845 cc's. The 24-hour total intake was documented as 1400 cc's. Residents Affected - Few 11/15/24 the intake for day shift was 425 cc's, intake for pm shift was 500 cc's, and intake for night shift was 30 cc's. The total equaled 955 cc's. The 24-hour total intake was documented as 1400 cc's. During a concurrent interview and record review on 1/10/25 at 2:22 p.m., with the director of nursing (DON), Resident 1's Intake Record and the Calculated 24-hours Intake Record dated 11/8/24-11/15/24 were reviewed. When asked if the daily intake record totals should match the 24-hour intake record totals, the DON verbalized yes, the totals should match. The DON acknowledged the daily intake totals did not match the 24-hour intake totals and they should. The DON further acknowledged the intake totals were not accurate. During a review of the facility's policy and procedure (P&P) titled, Intake and Output dated 6/11/24, indicated in part . It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance. Intake and output shall be recorded by each shift. During a review of Resident 1's ED Physician Notes dated 11/16/24, indicated in part . Resident 1 was recently diagnosed with pneumonia, on 2 liters of oxygen via nasal cannula coming from skilled nursing facility for shortness of breath .Diagnosis: Sepsis with acute hypoxic (not enough oxygen in the blood) respiratory failure and pneumonia. 2. During a review of Resident 2's Physician Orders dated 9/5/24-11/13/24, the physician orders indicated to record intake each shift and record the total daily intake in ml/cc (milliliters/cubic centimeters) every shift for monitoring due to poor appetite. The physician orders indicated to calculate the 24 hours intake on the night shift. During a review of Resident 2's Nutrition Evaluation dated 9/6/24, indicated in part . meal intake assessment: 0-25%, fluid intake assessment: needs encouragement with fluid intake .IV support: yes .estimated fluid needs not less than 1500 cc/day. During a review of Resident 2's Intake Record and the Calculated 24-hours Intake Record dated 11/1/24-11/13/24, indicated on: 11/1/24 the intake for day shift was 250 cc's, intake for pm shift was 120 cc's, and intake for night shift was 120 cc's. The total equaled 490 cc's. The 24-hour total intake was documented as 700 cc's. Less than 1500 cc/day. 11/5/24 the intake for day shift was 200 cc's, intake for pm shift was 120 cc's, and intake for night shift was 60 cc's. The total equaled 380 cc's. The 24-hour total intake was documented as 560 cc's. Less than 1500 cc/day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555770 If continuation sheet Page 5 of 7 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 555770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camarillo Healthcare Center 205 Granada Street 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11/6/24 the intake for day shift was 400 cc's, intake for pm shift was 200 cc's, and intake for night shift was 120 cc's. The total equaled 720 cc's. The 24-hour total intake was documented as 750 cc's. Less than 1500 cc/day. 11/7/24 the intake for day shift was 200 cc's, intake for pm shift was 120 cc's, and intake for night shift was 120 cc's. The total equaled 440 cc's. The 24-hour total intake was documented as 700 cc's. Less than 1500 cc/day. 11/9/24 the intake for day shift was 200 cc's, intake for pm shift was 120 cc's, and intake for night shift was 120 cc's. The total equaled 440 cc's. The 24-hour total intake was documented as 420 cc's. Less than 1500 cc/day. 11/11/24 the intake for day shift was 100 cc's, intake for pm shift was 120 cc's, and intake for night shift was 120 cc's. The total equaled 340 cc's. The 24-hour total intake was documented as 600 cc's. Less than 1500 cc/day. 11/12/24 the intake for day shift was 100 cc's, intake for pm shift was 100 cc's, and intake for night shift was 30 cc's. The total equaled 230 cc's. The 24-hour total intake was documented as 600 cc's. Less than 1500 cc/day. During a concurrent interview and record review on 12/4/24 at 11:09 a.m., with the assistant director of nursing (ADON), Resident 2's Intake Record and the Calculated 24-hours Intake Record dated 11/1/24-11/13/24 were reviewed. ADON acknowledged the daily intake totals did not match the 24-hour intake totals and they should. ADON verbalized Resident 2 had an IV (intravenous-in the vein) infusion on 11/3/24 and 11/11/24, the nursing staff did not include the IV fluids infusion as part of the intakes and further verbalized they should have. The ADON further acknowledged the intake totals were not accurate. When asked how you know Resident 2 was receiving adequate fluids and hydration, when the intake totals were not accurate, ADON verbalized you look at other areas as well like lab results (the blood urea nitrogen) and meal intakes. ADON verbalized Resident 2's labs were all normal. When asked about the 24-hour totals not meeting the recommended number of fluids (no less than 1500 cc/day) per the Nutrition Evaluation , ADON verbalized if had concerns that the resident was not getting in enough fluids, could call the physician to increase the IV infusion rate. Further review of Resident 2's medical record had no other documentation that the physician was informed of Resident 2 not meeting the 1500 cc/day of recommended fluid intake. During a review of Resident 2's Lab Results dated 11/11/24, indicated in part .the blood urea nitrogen (BUN- a test to assess how well the kidneys are functioning, a higher-than-normal BUN level can indicate kidney problems, heart failure, dehydration) was elevated at 37 (higher-than-normal). The creatinine (a test to assess how well the kidneys are functioning, a higher-than-normal creatinine level can indicate kidney problems, heart failure, dehydration) was elevated at 1.73 (higher-than-normal). During a concurrent interview and record review on 1/10/25 at 2:00 p.m., with the director of nursing (DON), Resident 2's Intake Record and the Calculated 24-hours Intake Record dated 11/1/24-11/13/24 were reviewed. When asked if the daily intake record totals should match the 24-hour intake record totals, the DON verbalized yes, the totals should match. The DON acknowledged the daily intake totals did not match the 24-hour intake totals and they should. The DON further acknowledged the intake totals were not accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555770 If continuation sheet Page 6 of 7 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 555770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camarillo Healthcare Center 205 Granada Street 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 0692 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 2's ED Physician Notes dated 11/13/24, indicated in part . Resident 2 presents with altered mental status and failure to thrive .Over the past week, progressive there has been a progressive decline in her condition, including decreased mental status, not eating, and not following her normal routine .Resident 2 typically is able to converse and ambulate with assistance but unresponsive this morning . Diagnosis: Pneumonia, urinary tract infection (UTI), Sepsis and chronic kidney disease. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Intake and Output dated 6/11/24, indicated in part . It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance. Intake and output shall be recorded by each shift .the licensed staff will monitor the intake and output daily for timely follow-up and will do weekly evaluation to update MD (physician) if there is a need for continuation .the registered dietician will do the follow-up assessment review for recommendation if indicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555770 If continuation sheet Page 7 of 7