Health inspection·April 11, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 138) received appropriate care and services to manage an indwelling catheter (a tube inserted into the bladder to drain urine). This failure had the potential for Resident 138 to have an increased risk for an infection. Findings: During an observation on 4/9/24 at 11:03 a.m. in Resident 138's room, a foley catheter bag was laying on the floor next to the bed. During a concurrent interview and record review on 4/10/24 at 3:37 p.m. with Infection Preventionist (IP), Resident 138's electronic Medical Record (eMR) was reviewed. IP stated there was no doctor order or care plan for a foley catheter. IP further stated she has a list of all the residents who have foley catheters and Resident 138 is not on the list. During a concurrent observation and interview on 4/10/24 at 3:49 p.m. with IP in Resident 138's room, IP observed the foley catheter and stated, She does have a foley catheter. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 9/2014, the P&P indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections . Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks . The urinary drainage bag must be held or positioned lower than the bladder at all times . Be sure the catheter tubing and drainage bag are kept off the floor . Empty the collection bag at least every eight (8) hours . Catheter tubing should be strapped to the to the resident's inner thigh. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 2 of 14 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 04/11/2024 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)

F 0692 Provide enough food/fluids to maintain a resident's health. 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 consistently document the quantity consumed of nutrition intervention (purposely planned action) supplement (nutritional product added to the diet) for two of 12 sampled residents (Resident 30 and Resident 143) ensuring the accuracy of nutrition assessments and ability to monitor effectiveness. Residents Affected - Few This failure had the potential to ineffectively evaluate and delay timely revision of interventions needed to meet residents' nutrition needs. Findings: 1. During a review of resident 30's Nutritional Screen and Assessment (NSA), dated 3/16/24, the NSA indicated Resident 30's most recent weight was 150 pounds and was re-admitted with a 16-pound weight loss prior to arrival due to severe protein-calorie malnutrition (an energy deficit due to deficiency of protein) with poor meal intake in hospital prior to arrival. The NSA indicated further, .Estimated Nutrient and Energy Needs ([NAME]) . [NAME] not met with PO (oral intake of food) and diet provided. Recommend TwoCal Med Pass (nutrition supplement) 120 cc (quantity measured in cubic centimeter) TID (three times a day) 10a (10 a.m.), 2p (2 p.m.), HS (bedtime) . Juven (another type of nutrition supplement) one packet mixed with eight ounces H2O (water) BID (two times a day) to ensure [NAME] met, stabilize weight and promote wound healing. During a review of Resident 30's, Order Summary Report (OSR), dated 4/9/24, the OSR indicated under the Dietary-Supplements section, Juven (Formulary) two times a day for supplement for 30 days mixed with 8 oz (ounces) fluid (start date: 4/9/24, end date: 5/9/24), Magic Cup (Formulary) (a protein-rich frozen dessert similar to ice cream) one time a day for supplement give with lunch (start date: 4/9/24), TwoCal (Formulary) three times a day for supplement five 120 cc (start date: 4/9/24). During a concurrent observation and interview on 04/09/24 at 12:15 PM with Restorative Nurse Assistant (RNA). Observed Resident 30 in dining room receiving assistance from RNA with lunch meal, Residents Magic Cup supplement was on another table unopened. RNA verbalized that Magic Cup supplement would be offered to resident after resident was done with meal. During a concurrent interview and record review on 04/10/24 at 10:22 a.m. with a Licensed Nurse (LN) 2, Resident 30's Medication Administration Record [MAR], dated April 2024 was reviewed in the electronic health record (EHR). LN 2 stated she provided Resident 30 her nutritional supplements of Juven and Two Cal (2 Cal) Med Pass (to increase calories and protein) as ordered as indicated on the EHR MAR by a green check mark. LN 2 stated she had not been trained to document quantity of consumption of the nutrition supplements, and therefore did not. During an interview on 04/10/24 at 01:20 p.m. with the Clinical Registered Dietitian (CRD), CRD stated that she gets information from nursing staff or residents when assessing resident's supplements consumption quantities. CRD stated in order to accurately assess nutrition intake as compared to assessed daily needs, there would need to be consistent and accurate documentation of quantity of consumption of the ordered nutritional supplements that were prescribed for therapeutic purposes. CRD verified lack of consistent documentation of quantity of nutritional supplements consumed impeded monitoring for effectiveness in order to identify when an alternative nutrition approach may be necessary prior to outcome, such as weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 3 of 14 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 04/11/2024 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/10/24 at 1:30 p.m. with RNA, RNA verbalized nutritional supplements are documented in the electronic health record (EHR) as PO intake when they come on the meal trays and not differentiated between other food on the meal tray. RNA stated Resident 30 refused the Magic Cup on 4/9/24 but described that when Magic Cup was ordered for any resident, that the consumption of the Magic Cup would be included in overall percent meal intake. RNA stated there would be no documentation for the specific order of Magic Cup in the EHR when Magic Cup was provided on meal trays and no method to review quantity consumption of Magic Cup, at a later time. RNA stated oral liquid nutrition supplements such as a healthshake was documented as overall cc of fluid intake from all fluid sources on the meal tray, whether it was fluid from water (with zero calories) or the high calorie/high protein oral liquid nutrition supplement. During an interview on 04/10/24 at 01:35 p.m. with the Director of Staff Development (DSD), DSD stated that the meal, protein, fluid intake documentations are part of Certified Nursing Assistants (CNA), and Licensed Nurses new hire orientation but CNAs and LNs do not have formal training regarding the documentation of intake quantity of residents' nutritional supplements consumption. During an interview on 04/10/24 at 03:55 p.m.with Director of Nursing (DON) and Food Service Director (FSD), DON and FSD verified they did not have a system to quantify consumption of nutrition supplement (therapeutic interventions) orders separate from the overall percent meal intake of the diet order when nutrition supplements are provided on meal trays. DON verified nursing staff have not been consistently trained on documenting quantity consumed of nutrition supplement orders that are given during medication pass for effective monitoring of intake. During a review of facility's policy and procedure (P&P) titled, Nutritional Assessment dated October 2017, P&P indicated, dietitian, as part of the interdisciplinary team (IDT) shall identify an estimate of calorie, protein, nutrient, and fluid needs, and whether the resident's current intake is adequate to meet his or her nutritional needs. During a review of resident 143 Nutritional Screen and Assessment , dated 03/25/24 resident 143 weight was 112 pounds on 03/21/24, . appears thin and may benefit from nutrition supplement . The estimated nutrient and energy needs were calories: 1527-1782, protein 61 grams. Rec [recommended] 2cal Med Pass 120cc BID [twice a day] 10a, 2p (480 cal, 20g pro) x30d (for 30 days) to ensure ENN met. During review of resident 143 Nutrition - Amount Eaten with look back for past 14 days, dates started 03/29/24 and end 04/11/24 indicated that a check mark was placed under percentage eaten. Percentage amounts broken down. 0-25%, 26-50%, 51-75%, 76-100%. NPO (nothing by mouth), tube feeding, resident not available, resident refused, and not applicable. During a review of resident 143 Order Summary Report dated 04/11/24 indicated 2 Cal Med Pass 120cc twice a day was ordered on 03/27/24. During a review of resident 143 Medication Administration Record (MAR) dated April 2024, indicated 2 Cal Med Pass 120cc BID was documented at 10:00 a.m. and 2:00 p.m. indicated by a check mark and initials of person administering on dates 04/01, 04/02/ 04/03/, 04/05, 04/06, 04/07, 04/08, 04/09, and 04/10. The Chart Codes on MAR indicates a check mark equals administered. During a review of resident 143 MAR dated March 2024 indicated 2 Cal Med Pass 120cc BID was documented at 10:00 a.m. and 2:00 p.m. indicated by a check mark and initials of person administering on dates 03/27, 03/28, 03/29, 03/30, and 03/30. The Chart Codes on MAR indicates a check mark equals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 4 of 14 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 04/11/2024 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)

F 0692 administered. Level of Harm - Minimal harm or potential for actual harm During a review of facility's policy and procedure (P&P) titled, Nutritional Assessment dated October 2017, P&P indicated, dietitian, as part of the interdisciplinary team (IDT) shall identify an estimate of calorie, protein, nutrient, and fluid needs, and whether the resident's current intake is adequate to meet his or her nutritional needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 5 of 14 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 04/11/2024 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: 1. Expired items in the medication storage room and treatment cart were discarded and not readily available for staff use. 2. Medications and biologicals in locked compartments were stored at proper temperature controls. These failures had the potential for residents to receive expired and ineffective medications and supplies. 1. During a concurrent observation and interview on [DATE] at 2:37 p.m., in the facility's medication storage room with the Director of Nursing (DON), a sealed First Aid Kit (FAK - a set of materials and tools used for giving emergency treatment) was noted without a visible expiration date label. DON was asked how staff would verify if the contents of the kit were still usable. DON opened the kit and revealed a label indicating the FAK expired in 2022. During a concurrent observation and interview on [DATE] at 3:16 p.m., with licensed nurse (LN) 1, the facility's treatment cart was inspected. The cart was observed to have opened, single- use and steri-strips (sterile, breathable adhesive strips that keep small wounds closed and saline (sterile cleaning solution) bottles stored. LN 1 verbalized these opened, leftover items should have been discarded. During a review of the facility's policies and procedures (P&P) titled, Storage of Medications, dated 4/08, the P&P indicated in part . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock 2. During a concurrent observation and interview on [DATE] at 2:37 p.m. in the facility's medication storage room, with the Director of Staff Development (DSD), the room temperature reading was noted at 78 degrees Fahrenheit (F), and the refrigerator temperature reading was noted at 58 degrees F. DSD verbalized the temperature readings were out of range. During a concurrent observation and interview on [DATE] at 3:40 p.m., in the facility's medication storage room, with LN 3, the room temperature reading was noted at 79 degrees F, and the refrigerator temperature reading was noted at 48 degrees F. LN 3 verbalized the temperature readings were still out of range. During a review of the facility form titled, Temperature Log, dated 4/24, the log indicated, Medication Room Temperature range 65-75 degrees F . Refrigerator temperature Range 35-45 F. During a review of the facility's P&P titled, Storage of Medications dated 4/08, the P&P further indicated, .Medications requiring refrigeration or temperatures between 2 degrees Centigrade (C) (36 F) and 8C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 6 of 14 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 04/11/2024 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)

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 ensure: 1. Food was stored properly in accordance with professional standards of food service safety when a box of raw ground hamburger was stored above pork cutlets in the walk-in refrigerator. 2. Cooked pasta, a TCS (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) food, was documented on the cool down log. 3. There was an appropriate air gap between the dish machine drain and the floor sink drain to prevent contaminated water from backing up into the dish machine should a problem arise with the floor drain. 4. The high temperature dish machine manufacturer guidelines were followed. These failures had the potential to place residents at an increased risk of a foodborne illness. Findings: 1. During an observation on 4/8/24 at 09:55 with the Food Service Director (FSD) in the main kitchen, inside the walk-in refrigerator was an open box of raw ground beef stored above a shelf that had a box of raw pork cutlets. During concurrent observation and interview on 04/08/24 at 02:15 p.m. with FSD in the main kitchen, a poster titled Proper Food Storage Order was posted on the wall next to the walk-in refrigerator. The poster indicated raw whole meat (pork cutlets) should be stored above raw ground meats (ground beef). FSD confirmed the meats were not stored safely when the ground beef was stored above the pork cutlets. During a review of facility policy and procedure (P&P) titled, Meat Cookery and Storage, dated 5/20/2020, the P&P indicated, Whole cuts of beef and Pork should be stored on top of ground meat. 2. During a concurrent observation and interview on 4/8/24 at 10:10 a.m. with FSD in the walk-in refrigerator in the main kitchen, there was a container labeled pasta, dated 4/5/24, on a shelf. FSD stated the cooked pasta was for the residents residing in the assisted living. During a concurrent observation and interview on 4/8/24 at 10:25 a.m. with the cook/food service (FS), FS observed the pasta in the walk-in refrigerator. FS stated he cooked the pasta and forgot to document the cool down process on the cool down log. During a concurrent interview and record review on 04/08/24 at 10:35 a.m. with the Kitchen Supervisor (KS) and FSD, KS stated the pasta in the refrigerator was for use in both the assisted living and the skilled nursing for the macaroni, cheese and tomato bake for the residents dinner on 4/8/24. FSD reviewed the cool down log and verified the pasta was not documented on the log and should have been. During a review of facility's policy and procedure (P&P) titled, Cooling Monitor for Hazardous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 7 of 14 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 04/11/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Foods, dated 5/20/2020, the P&P indicated .using the form 406, record food temperature every hour. Food should be cooled from 140 degrees to 70 degrees Fahrenheit (F) within 2 hours and cooled from 70 degrees to 41 degrees F in an additional 4 hours. 3. During an observation on 04/08/24 at 10:34 a.m., in the kitchen titled pantry, a black plastic pipe that was attached to a copper-colored metal pipe located near the dishwash machine was observed. The black plastic pipe extended approximately two inches below the flood level rim of the floor sink drain. The copper pipe was observed to be below the flood level rim of the floor sink drain. During a concurrent observation and interview on 04/08/24 at 2:38 p.m. with the Director of Maintenance (DOM) in the pantry kitchen, DOM stated the black plastic pipe was hooked up to the dishwash machine for drainage. DOM stated the copper pipe was zip tied to the black plastic pipe to hold it up, but the copper pipe was not being utilized for drainage. DOM verbalized he did not believe the black plastic pipe used for drainage from the dish-machine needed an air gap. During an observation and concurrent interview on 04/08/24 at 2:42 p.m. with Food Service Director (FSD) in the pantry kitchen, FSD observed the pipe used for drainage from the dishwash machine. FSD stated there was not an appropriate air gap and it did not meet the FDA (Food and Drug Administration) food code guidelines that required the pipe to be above the rim by one inch. During a review of an email communication on 04/08/24 at 3:47 p.m. with the Department of Health Care Access and Information (HCAI), the e-mail indicated, we never allow plastic pipe and that an air gap 1 (one) inch above the floor sink drain rim was required for the dishwash machine. During an interview with DOM on 04/08/24 at 4:15 p.m., DOM stated the drainage pipe should be one inch above the floor sink rim for an air gap, and it was not. During a review of the FDA Food Code (FDAFC), dated 2022, the FDAFC indicated, 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). During a review of the FDA Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Backflow Prevention, Air Gap .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. 4. During a concurrent observation and interview on 04/10/24 at 1:52 p.m. with Dietary Aid (DA) in the kitchen called Pantry, DA 1 was observed running resident dishes through the high temperature dish machine (HTDM). DA1 observed the digital temperature reading displayed on the screen located on the HTDM. DA 1 stated the wash temperature was 138 degrees Fahrenheit (F), and rinse (final rinse) temperature was 158 degrees F. DA1 stated the HTDM wash cycle should reach 150 degrees F for wash and 180 degrees F for rinse. DA 1 was observed to continue to use the HTDM to wash resident's dishes from the lunch meal. DA1 and DA2 stated they use the HTDM for resident's plates, lids, domes, mugs, cups, utensils and meal trays. DA 1 and DA 2 stated the pans used to store food in the steam table were the only items that were washed in the main kitchen's HTDM. During a concurrent observation and interview on 04/10/24 at 2:15 p.m. with FSD in the Pantry kitchen, FSD observed a load of dishes run through the HTDM. FSD stated the digital temperature reading indicated the wash temperature reached 138 degrees F and the final rinse temperature reached 171 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 8 of 14 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 04/11/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some degrees F. FSD stated dietary aides had not reported a problem with the HTDM temperatures since it had been installed a couple of months ago. During a concurrent observation and interview on 04/10/24 at 2:17 p.m. with FSD and Kitchen Manager (KM), a new cycle of dishes was run through the HTDM. KM stated the wash temperature reached 145 degrees F and the final rinse temperature reached 170 degrees F. KM stated the dishes were not being washed and sanitized in accordance with the HTDM manufacturer's guidelines. During a review of an invoice (from the manufacturer of the HTDM), dated 02/26/24, the invoice indicated the HTDM was installed and in use at the facility since 2/26/24. During a review of the facility's policy and procedure (P&P) titled, Recording of Dish Machine Temperatures, dated 08/29/23, the P&P indicated, .record temperature every shift on Dishmachine Temperature Log (FORM 408) or other designated form or on Food Temperature and Sanitation Record (FORM 401B) ., High Temperature Dishmachines . wash temperature 150 - 165 degrees (160 degrees at rack level) and rinse temperature 180 degrees or greater ., Report temperatures that are less than required levels (see above) to the Director of Food and Nutrition Services or other clinically qualified nutrition professional and immediately convert to paper service until the temperature is corrected. During a review of the manufacturer's directions located on a data plate (DP) affixed to the HTDM, the DP indicated the minimum required wash temperature was 155 degrees F and minimum rinse temperature was 180 degrees F. During a review of the facility's Dishmachine Temp Log, dated 2/26/24 through 4/9/24, the Wash column indicated the wash water temperature was less than 155 degrees F for 59 of 162 logged entries. The Dishmachine Temp Log, dated March 2024, indicated the Rinse (final rinse for sanitizing) was less than 180 degrees F for 7 of 93 logged entries. The Dishmachine Temp Log indicated, Notify supervisor when temps or sanitizer are out of range. 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 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) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 9 of 14 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 04/11/2024 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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 facility policy and procedure (P&P) for foods brought in by family/visitors was implemented when staff were unaware of the P&P and there lacked clear guidance on location of a designated refrigerated area for this purpose. Residents Affected - Few This deficient practice had the potential to deny residents, family, and visitors their right to store outside food safely for later consumption. Findings: During an interview on 04/08/24 at 2:29 p.m. with a Certified Nursing Assistant (CNA) 1, CNA 1 stated, I do not know if family can bring in food from home to be stored for a resident. CNA 1 verbalized that if family did bring in food, they usually come during mealtime and no food is stored. CNA 1 verbalized that she has not had training regarding storing foods brought in from home. During an interview on 04/08/24 at 2:30 p.m. with CNA 2, CNA 2 stated the facility allows food from outside brought by family. CNA 2 verbalized the Food Service Director (FSD) checks the food first and it gets stored in the kitchen. During an interview on 04/08/24 at 2:34 p.m. with FSD, FSD verbalized that it is ok for family to bring in outside foods if it follows the resident's prescription diet. FSD stated, The facility does not store outside food for residents at the facility. During an interview on 04/09/24 at 3:15 p.m. with Director of Marketing (DMK) and FSD, DMK verbalized he is in charge of admissions for new residents. DMK verbalized that the family and/or resident will sign the Food Brought by Family/Visitors policy on admission. FSD stated that it has not been the practice to educate staff on food brought from home. During an interview with Director of Staff Development (DSD) on 04/10/24 at 1:35 PM, DSD stated that meal, protein, fluid intake and (activities of daily living (ADLs) are included during Staff training but there is no formal training on foods brought from home. During a review of the facility's policy and procedure (P&P) titled, Foods [NAME] by Family/Visitors, dated 11/2017, the P&P indicated, .7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food, . b. Perishable foods must be stored in a re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item, and the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 10 of 14 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 04/11/2024 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure resident medical records were kept confidential when the Discharge Summary (DS) of one unsampled resident (Resident 8) was found attached to the DS of one sampled resident (Resident 140). This failure resulted in a breach of protected health information for Resident 8 and the inaccurate discharge information for Resident 140 . Findings: During a review of Resident 140's clinical record, a document titled Discharge Summary, dated 3/25/24 under Resident 8's name was found attached to Resident 140's DS, also dated 3/25/24. During a concurrent interview and record review on 4/9/24 at 3:36 p.m., with the Director of Nursing (DON), Resident 140's DS, dated 3/25/24, was reviewed. The DON indicated that the DS of Resident 8 was attached to Resident 140 electronic medical information and agreed that Resident 8's discharge information was mistakenly scanned in Resident 140's clinical record. During a review of the facility's policy and procedure (P&P) titled, Release of Information, dated 11/09, the P&P indicated in part, Our facility maintains the confidentiality of each resident's personal and protected health information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 11 of 14 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 04/11/2024 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)

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** Based on observation, interview, and record review the facility failed to maintain an effective infection prevention and control program when: Residents Affected - Many 1. A hand washing sink area was not accessible for staff use in a resident room identified as requiring transmission-based precautions (TBP - precautions put in place to prevent or control infections). 2. C-DIFF (Clostridium Difficile - an infection from a bacterium that causes diarrhea) feces contaminated briefs were discarded in the same trash can intended for doffing (removal) of personal protective equipment [(PPE) isolation gowns and gloves]. 3. A clean medication preparation area on the medication cart was contaminated when a jacket, personal supply bag, and blood pressure (BP) cuff were stored on it. 4. A BP cuff removed from a room requiring TBP was placed on top of the clean PPE supply cart for cleaning. 5. Medication cart trash was overflowing. 6. Water management test kits in use were expired. 7. Dirty laundry was transported through the clean laundry area. These failures had the potential to result in the spread of harmful microorganisms to staff, residents, and visitors. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions, dated 10/18, the P&P indicated in part, Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection . Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. During a review of Resident 138's Order Summary Report (OSR) dated [DATE], the OSR indicated, CONTACT PRECAUTION FOR C-DIFF . Order date [DATE]. During a concurrent interview and observation on [DATE] at 3:30 p.m. with Resident 138 in their room, Resident 138 verbalized staff did not wash their hands before exiting the room. Resident 138's room was identified as requiring contact precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). Resident 138's sink area was cluttered with a pink wash basin preventing the washing hands before exiting the room. During an interview on [DATE] at 2:15 p.m. with Infection Preventionist (IP), IP verbalized that she was aware of the pink wash basin on the sink counter in Resident 138's room. IP also verbalized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 12 of 14 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 04/11/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that there was very limited storage area in the resident bathroom. IP further stated, Yes, the pink wash basin is considered contaminated and does get in the way of staff trying to wash their hands. During a review of the P&P, titled, Isolation - Categories of Transmission-Based Precautions, dated 10/18, the P&P further indicated, . Staff and visitors will wear gloves (clean, non-sterile) when entering the room . Gloves will be removed and hand hygiene (hand washing) performed before leaving the room . Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 2. During a concurrent observation and interview on [DATE] at 3:49 p.m. in room [ROOM NUMBER], IP was observed doffing her PPE and then discarding them in the designated trash. The trash was full. IP placed her unprotected hands onto the trash and pushed down to compact the trash to allow the trash lid to close. IP was asked if there were C-Diff contaminated briefs in the trash. IP looked in the trash and stated, Yes, there are briefs in there and there should not be. During a review of the facility's P&P titled, Isolation - Categories of Transmission-Based Precautions, dated 10/18, the P&P indicated in part, Contact Precautions . Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. 3. During an observation on [DATE] at 11:22 a.m. outside room [ROOM NUMBER], a medication cart in use had a personal jacket thrown over the pill crusher and a personal supply bag stored on the medication preparation area. During an observation on [DATE] at 11:20 a.m. outside of room [ROOM NUMBER], a licensed nurse (LN) 4 took off her jacket and placed it on top of the pill crusher, stethoscope, and personal bag containing a thermometer, oxygen saturation monitor, and bandage scissors. All in the medication preparation area of the cart. Review of the Centers for Disease Control and Prevention (CDC) website, https://www.cdc.gov/hai/prevent/resource-limited/special-areas.html#anchor_1585593828801, accessed on [DATE], indicated, Areas where medication is prepared (including pharmacies and clinical areas) area high-risk areas in which high degree of asepsis [free from germs that can cause disease] is required. 4. During an observation on [DATE] at 11:22 a.m. outside TBP room [ROOM NUMBER], LN 4 exited room [ROOM NUMBER], a contact isolation precautions room, carrying a BP cuff and placed it on the clean medication preparation area of the medication cart. During an observation on [DATE] at 11:20 a.m. outside TBP room [ROOM NUMBER], LN 4 took a BP cuff from the top of the medication cart then brought it into room [ROOM NUMBER], a contact isolation precautions room for CDI. During a concurrent observation and interview on [DATE] at 11:25 a.m. with LN 4, LN 4 was observed to exit the TBP room [ROOM NUMBER] carrying a BP cuff. LN 4 placed the BP cuff on top of the clean PPE supply cart next to a box of clean face masks to use the bleach wipes on it. LN4 stated she needed to wipe down the BP cuff, then it should dry within three minutes. When pointed out she placed a contaminated BP cuff on the clean PPE storage cart LN 4 stated, Oh Ya, that makes sense. When asked again about the dwell time (the amount of time that a disinfectant must remain visibly moist on a surface) LN 4 verbalized that it would have taken a long time for the BP cuff to dry and be usable if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 13 of 14 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 04/11/2024 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)

F 0880 done correctly. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 2:15 p.m. with IP, IP verbalized that she didn't know why there wasn't a dedicated BP cuff in the contact isolation room. Residents Affected - Many During a review of the facility's P&P titled, Isolation - Categories of Transmission-Based Precautions, dated 10/18, the P&P indicated in part, When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope (a medical device for listening to internal body sounds such as heart beats and breathing) sphygmomanometer (a medical device to measure blood pressure), or digital thermometer will be dedicated to a single resident. 5. During an observation on [DATE] at 11:22 a.m. outside room [ROOM NUMBER], trash on the side of the medication cart was overflowing. During a concurrent observation and interview on [DATE] at 1:05 p.m. with LN 4, trash on the side of the medication cart was overflowing. LN 4 stated, Yes. It's because the trash bag is too big. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 6/21, the P&P indicated in part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment. 6. During a review of the facility's P&P titled, Legionella (a severe form of pneumonia caused by infection) Water Management Program, dated 7/17, the P&P indicated in part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella . The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. During a concurrent interview and observation on [DATE] at 12:15 p.m. with the Director of Maintenance (DOM) in the maintenance office, DOM verbalized that [company name] tests the cooling tower (a heat exchanger used to cool water and are breeding grounds for Legionella bacteria if they are not properly disinfected and maintained). DOM presented a test kit and also verbalized that the company workers test the cooling tower every month. The contents of the kit expired 5/19. DOM further verbalized being aware the kit was expired for a couple of months. DOM additionally stated, I have some on order. 7. During a concurrent observation and interview on [DATE] at 1 p.m. with a laundry worker (LW) in the clean laundry room, dirty laundry left in the hallway at the clean laundry door was observed to be transported through the clean laundry room and deposited in the dirty laundry room. LW stated, I'm sorry, when asked how she moved the dirty laundry from clean to dirty area. During a review of the facility's P&P titled, Laundry and Bedding, Soiled, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555876 If continuation sheet Page 14 of 14