Alta Healthcare Center of Camarillo

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 3 sampled residents (Resident 1 and Resident 2) had their call light responded to timely. This failure had the potential to result in residents' needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for 2 of 13 sampled residents (Residents 7 & 193) when: 1. Resident 7 had missing care plans for pressure injuries (an injury that breaks down the skin and underlying tissue) on the sacral (tail bone) and left heel and a wound on the right anterior (in front of) leg. 2. Resident 193's bed rail was used while in bed. These failures placed the residents at risk of not having their care needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk of entrapment (the state of being caught in between something) prior to the use of bilateral bedrails for 1 of 13 sampled residents (Resident 193). This failure had the potential to result in avoidable injuries to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the order for pain medication management (Tylenol and Hydrocodone-Acetamenophen) was clarified with the physician with the correct pain parameters in relation to pain level in 1 of 13 sampled residents (Resident 201). This failure had the potential for Resident 201's pain to be mismanaged.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment for 1 of 13 sampled residents (Resident 35) when oxygen and nebulizer tubings in use were not labelled and dated to determine when next to change the tubings. This failure had the potential to result in the transmission of infection to the resident.

Inspectors wroteBased on record review and interview, the facility failed to follow its policy and procedure when a care plan was not developed for a suprapubic catheter (is a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) for one of two sampled residents (Resident 1). This failure had the potential to delay Resident 1's care and treatment needed.

Inspectors wroteBased on record review and interview, the facility failed to complete an individualized care plan for a pressure ulcer (an injury that breaks down the skin and underlying tissue) on the sacrum (tail bone) for one of two sampled residents (Resident1). This failure had the potential for health, safety and care needs to go unmet if Resident 1's condition changed.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective infection prevention and control program when: 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 138) had a care plan developed and implemented for foley catheter (a tube inserted into the bladder to drain urine) use. This failure resulted in interventions not being established to guide the provision of high-quality care and had the potential to result in unrecognized complications.

Inspectors wroteBased 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.

Inspectors wroteBased 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. This failure had the potential to ineffectively evaluate and delay timely revision of interventions needed to meet residents' nutrition needs.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. This deficient practice had the potential to deny residents, family, and visitors their right to store outside food safely for later consumption.

Inspectors wroteBased 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 .

Inspectors wroteBased on interview and record review, the facility failed to provide written notice for one of two sampled residents (Resident 1) to the resident's responsible party (RP - person designated as being responsible for another person's medical and/or financial decisions) and provide an explanation why the resident was going to be moved to another room before the resident was moved. This failure resulted in Resident 1 being moved to another room without RP knowledge.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation were implemented when the ice machine was not maintained in a sanitary manner. This failure had the potential to place the residents at an increased risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facilty failed to ensure: 1. An opened tube of eye lubricant found in the medication storage room was labeled and dated. 2. Expired supplies in the treatment cart were discarded and not available for use. These failures had the potential to cause harm to the residents as a result of unsafe medication dispensing and use of ineffective treatment supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene was performed during an active outbreak of Clostridium difficile [CDI- is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon] infection for one of three sampled residents (Resident 96). This facility failure had the potential to cause a mass outbreak in facility, which can result to dehydration, malnutrition, and death.