Health inspection·June 13, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure its Abuse/Injuries of Unknown Origin policies and procedures were implemented when one of two residents (Resident 1) was found by the responsible party (RP) and family with unreported injuries of unknown origin (abrasion to right shoulder and skin discoloration/bruise on the chin and on the left cheek) This failure had the potential for abuse and injuries to occur with no monitoring and follow up, thereby placing the residents at risk for increased abuse, injuries, or harm. Findings: During an observation on 5/16/24 at 3:06 p.m., Resident 1 was observed in her room, in bed, awake, responsive, and covered with a blanket from neck to lower extremities. Resident 1's bed was in a low position with bilateral floor mattresses folded by the wall. Three family members (FM) were at the bedside visiting. Resident 1 was further observed with reddish, purplish skin discoloration under the chin, about the size of a quarter and greenish yellowish skin discoloration on the left cheek. During an interview on 5/16/24 at 3:06 p.m., with Resident 1 and family member (FM1), FM1 verbalized on 5/9/24 around 9 a.m., while at the facility's dining area with Resident 1, RP and FM1 noticed a bandage on resident's right shoulder area. Resident 1 was not able to recall any accidents, falls, injuries or trauma to any part of body. During a phone interview on 5/16/24 at 6:45 p.m., with the RP, the RP indicated on 5/9/24 around 9 a.m., the RP and FM1 noted a bandage on the resident's right shoulder. The RP sought out the administrator (ADM) and asked what happened to (Resident 1) since the RP and the family received no notification of a fall or an incident occurring. Per RP, the ADM stated he is not clinical but will ask the Director of Staff Development (DSD) to talk to the RP. The RP indicated on 5/9/24, aside from the right shoulder skin abrasion, Resident 1 was also noted to have skin discoloration/bruise on the chin and on the left cheek and no one from the facility seemed to know what happened or even noticed the skin abrasion/discoloration until it was brought up to their attention by the RP to the facility staff. During an interview on 5/16/24 at 3:50 p.m., with the Director of Nursing (DON) and the facility ADM, the ADM verbalized being approached by Resident 1's RP on 5/9/24 around 10 a.m., inquiring about what happened to Resident 1's right shoulder with bandage. The ADM verbalized he was not clinical and referred the RP to the DSD, ADM then informed the DON about RP's concerns. DON verbalized on 5/9/24 (unable to recall what time), sometime in the morning, spoke to Resident 1's RP about the resident's skin issues. According to the DON, DSD found Resident 1 on 5/9/24 with an abrasion on the right Page 1 of 3 555876 555876 06/13/2024 Alta Healthcare Center of Camarillo 6000 Santa Rosa Road Camarillo, CA 93012

F 0600 shoulder and applied a band aid/bandage on the area. DON was not able to produce any documentation by the DSD regarding the resident's skin condition. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 1's History & Physical (H&P), dated 5/9/24, the H&P indicated, Resident 1 was admitted to the facility with diagnoses including, Acute Post-hemorrhagic anemia (a condition in which a person quickly loses a large volume of blood), Gastrointestinal bleeding (bleeding disorder of the digestive tract), cholelithiasis (stones in the gall bladder), cystitis (swelling of the bladder, Chronic Kidney Disease (kidney damage), encephalopathy (toxins in the brain causing changes), diabetes (uncontrolled sugar level in the blood), unspecified dementia (an impairment of cognition without a specific diagnosis), and hypertension (increase in blood pressure). During a review of the admission Progress Notes (PN), dated 5/7/24, at 8:58 p.m., the PN indicated, Resident 1 was awake, alert, and oriented x 3 (three), able to verbalize needs, with skin intact, and no complaints of pain. During a review of the Physical Therapy (PT) treatment encounter notes on 5/9/24, signed by the therapist at 5:40 p.m., the PT notes indicated, Resident 1 requires, moderate assistance from sitting to standing and maximum assistance to moderate assistance with transfer. During a review of Resident 1's document for change of condition (SBAR - Situation Background Appearance Review and Notify) dated 5/9/24, at 11 a.m., authored by the DON, the SBAR indicated, Resident 1's RP and doctor were notified of the left shoulder abrasion and pain condition. During an interview on 5/16/24 at 5:51 p.m. with Licensed Nurse (LN2), LN2 stated on 5/9/24 (unable to recall what time) Resident 1's RP and FM2 asked when and where the resident sustained the skin changes on the right shoulder, chin area and left cheek. LN2 stated, she responded to FM2 she was not aware of any skin changes as nothing was endorsed by the outgoing shift (night and morning shift). LN2 reviewed Resident 1's documentation with the FM2 in attendance, and review of the night shift nursing documentation indicated, there was no documentation regarding skin changes/abrasions/discoloration. LN2 was not able to locate any further documentation about a change of condition, change in skin assessment, or documentation from other nursing staff, DSD, or DON. During a review of the facility's policy and procedure (P&P) titled, Reporting Suspicious Injury of Unknown Source, dated 11/30/22, the P&P indicated, 1. The facility shall report any injury when ALL of the following criteria are met: The source of the injury was not observed by any person, and the source of the injury could not be explained by the resident, and the injury is suspicious because of: a. The extent of the injury, or b. the location of the injury (e.g., the injury is located in an are not generally vulnerable to trauma), or c. the number of injuries observed at one particular point in time, or d. the incidence of injuries over time .Interview Process/Procedure: 12. Any injury of unknown origin will be reported by the facility administrator, or his/her designee to the following persons or agencies within 2 hours either by telephone, email or in writing (SOC 341) after the report is made, if events that caused the allegation involve abuse or result in serious body injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. During the review of the facility's P&P titled, Abuse Prevention Program, dated 12/2022, the P&P indicated, POLICY: To promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment. Type of Abuse: . 7. Injury of unknown source . VI. A The facility shall respond to the abuse allegation (s) immediately by protecting the 555876 Page 2 of 3 555876 06/13/2024 Alta Healthcare Center of Camarillo 6000 Santa Rosa Road Camarillo, CA 93012

F 0600 Level of Harm - Actual harm Residents Affected - Few alleged victim and integrity of the investigation. b. The facility shall examine the alleged victim for any physical signs of injury, including but not limited to psychological, and psychosocial effect .VII. Reporting/Response a. The facility shall report any and all allegation of abuse to the District CDPH (California Department of Public Health), Local Ombudsman and/or Local Law Enforcement, either by phone, email or facsimile within 2-hour timeframe. 555876 Page 3 of 3