Health inspection·September 4, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the family member or contact person of one of three sampled residents (Resident 1), was notified appropriately and in a timely manner, of the resident's significant change in condition requiring an emergency room transfer. This failure had the potential to result in physical and emotional trauma to both resident and family member. Findings: During a review of Resident 1's, admission Record (AR), dated 6/21/23, the AR indicated in part, Resident 1 was a [AGE] year-old male resident, who was admitted to the facility on [DATE] and discharged [DATE]. The AR also indicated, Resident 1 as the primary contact person but has named (name and telephone number) as a second contact person. During a review of Resident 1's, Minimum Data Set (MDS) Assessment (a health status screening and assessment tool used for all residents of long term care facilities), dated 6/28/23, Section C - Cognitive Patterns of the assessment indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a 15-point screening measure that evaluates memory and orientation with the score interpretations as follows: 13-15 = cognitively intact, 8-12 = moderately impaired, 0-7 = severely impaired) Score of 15. During a review of Resident 1's, Change of Condition (COC) Evaluation, dated 6/26/23, the COC evaluation indicated in part, Resident 1 complained of severe right hip pain, rated at a level eight out of ten (8/10) on the numeric ratings scale (pain scale: 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain, 10 = very severe pain). On further review of the COC evaluation, the section under, Name of family/resident representative notified, failed to indicate that a second contact person was notified of Resident 1's change of condition. During a review of Resident 1's, Transfer Form V5, dated 6/27/23, the form indicated in part, Additional relevant information: Resident (1) complained of constant pain on his right hip . MD notified. Send resident (1) to ER (emergency room) for further evaluation per MD. Further review of the form, the section under, Key Contacts failed to indicate a second contact person was notified of Resident 1's unplanned transfer to the ER. During a concurrent interview and record review, on 7/17/23 at 3:30 p.m., with the Director of Nursing (DON), Resident 1's, COC Evaluation, dated 6/26/23, and Transfer Form, dated 6/27/23, were (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555876 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 555876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Healthcare Center of Camarillo 6000 Santa Rosa Road Camarillo, CA 93012 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)