Health inspection·June 20, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview and record review, the facility failed to report to the State Agency (Department) and the Ombudsman in a timely manner when injuries/abrasions of unknown origin were noted on Resident 1. This failure had the potential to result in further harm to the resident and to other residents. Findings: On 5/14/24 the facility submitted a report to the Department regarding an injury of unknown origin for Resident 1. The facility's investigation indicated, On Thursday morning 5/8/24, Director of Staff Development (DSD) noticed a skin abrasion on (Resident 1) shoulder. DSD checked for documentation and did not see anything reported, so DSD cleaned abrasion with normal saline, placed a bandage on the site, and reported finding during morning clinical meeting . That same morning . Director of Nursing (DON) delegated skin check to Treatment Nurse, who noted the 1.5cm x 1cm x 0.1 skin abrasion on right shoulder and also noted skin discoloration developing on chin, measuring 0.2cm x 0.2cm. The facility did not report Resident 1's injuries of unknown origin until 5/14/24, six days after the facility claimed it was noted on 5/8/24. During an observation on 5/16/24 at 3:06 p.m. in Resident 1's room, Resident 1 was observed inside the room on the bed, awake, responsive, in and out of sleep, 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, the size of a quarter and greenish yellowish skin discoloration on the left cheek. During a phone interview on 5/16/24 at 6:45 p.m. with the Responsible Person (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 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 notice the skin abrasion/discoloration until it was brought to their attention by the RP to the facility staff. During an interview on 5/21/24 at 3:45 p.m. with facility ADM, ADM verbalized the family had notified the facility of skin issues on 5/9/24 and the facility should not have waited until 5/14/24 to report the incident to the Department. ADM stated about the discrepancies on the dates on his report (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 06/20/2024 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)