Camarillo Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a facility wall inside rooms [ROOM NUMBERS], occupied by residents were free from scuff marks, multiple scratches and uneven texture. This failure had the potential to affect the overall sense of an orderly, clean home environment for the occupying residents of both rooms. During a concurrent interview and record review, on 6/5/26, beginning at 8:37 a.m., with the Maintenance Director (MD), the MD verbalized the maintenance department in part relies on staff to report environmental concerns to them. The MD verbalized at each nursing station there was a maintenance binder where staff could write down items that need to be fixed/addressed. Both maintenance logs were reviewed which indicated there were no current items that needed to be fixed/addressed. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the comprehensive care plan was developed and implemented for two of the 10 sampled residents (Resident 41 and Resident 11).1. Resident 41 had no care plan with interventions due to the medical diagnosis related to Cannabis Abuse. 2. Resident 11's care plan interventions related to restorative nursing assistance (RNA) exercises/services were not consistently completed/documented. 1. During a concurrent record review and interview, on 6/5/26, beginning at 1:45 p.m., with the Assistant Director of Nursing (ADON) Resident 41's care plan and medical diagnosis was reviewed. Resident 1's Face Sheet indicated a diagnosis of Cannabis Abuse, Uncomplicated, with an onset date of 5/6/26. The ADON verbalized and confirmed Resident 1 did not have a care plan or interventions for the Cannabis Abuse, Uncomplicated diagnosis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan for cognitive impairment/dementia, for one out of five sampled residents (Resident 1), was updated and revised after a significant change of condition. This failure had the potential to result in Resident 1 not receiving care based on current health status and at risk for unmet care needs.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the provision of resident care and services were performed within acceptable standards of nursing practice for two of eight sampled residents (Residents 12 and 66) when:1. Physician orders and instructions were not followed for Resident 12.2. Comprehensive and timely pain assessments/reassessments were not performed for Resident 66.3. The timing of insulin (a hormone that lowers the level of glucose [simple sugar]) injections (forcing medication into the body using needle and syringe) for Resident 45 was not followed per physician's prescription instructions. These failures had the potential to compromise Residents 12 and 66's health and safety from unsafe nursing care practices and had the potential to cause dangerous drops in Resident 45's blood sugar level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate, effective system for monitoring parameters of nutritional status when the quantity of consumption for therapeutic (to cure or restore to health) liquid nutritional supplements were not documented for one of five sampled residents (Resident 10). This facility failure of not documenting the accurate amount of therapeutic supplements taken had the potential to ineffectively evaluate nutritional interventions and delay an alternative nutrition approach, if necessary, to help prevent or minimize a potential negative outcome and possible continued weight loss for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices and maintain a safe, and sanitary environment when:1. One staff member was observed feeding two residents at the same time. 2. One staff member was observed handling resident food with bare hands. 3. Three direct care staff were observed not adhering to proper hand hygiene. These facility failures had the potential for cross contamination of microorganisms and had potential to spread infection to residents and jeopardizing the quality and safety of care.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and sanitary environment by ensuring the dining area corridor wall was intact, dry, and free of insects. This facility failure placed residents at risk of exposure to mold from humid or wet walls, which also attracted insects.

Inspectors wroteBased on record review and interview, the facility failed to; 1. Ensure the attending physician (MD1) for one of two sampled residents (Resident 1) conducted a review of resident's medications at each visit. 2. Ensure Resident 1's physician (MD 1) wrote, signed, and dated a progress note at each visit and note was in the resident's medical record. The facility's failures resulted in the physician's progress notes being inaccurate.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of two sampled residents (Resident 1) physician conducted visits at least once every 60 days and timely within the 10 days of the required date of the visit. The facility ' s failure resulted in the resident not being evaluated timely thus potentially having a negative outcome.

Inspectors wroteBased on interview and record review the facility failed to ensure an identified pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) with care issues was assessed and documented for one of two sampled residents (Resident 2). This failure had the potential to impede the treatment and interventions of the existing pressure ulcers which can result in deterioration affecting the overall medical condition of Resident 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. One of 25 sampled residents (Resident 624) was treated with dignity (the feeling of being valued and respected as a person) and respect, during and after a room change. This failure had the potential to negatively affect Resident 624's sense of self-worth and care needs to go unmet. 2. One resident (Resident 31) was free of foul body odor. This failure had the potential to violate resident 31's rights to receive quality care and freedom from neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD - a written statement of a person's wishes regarding medical treatment) was noted in residents re-admission agreement for one of 25 sampled residents (Resident 85). This failure had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 85's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain two rooms in good repair, for one unsampled Resident (Resident 14) and one sampled Resident (Resident 87). 2. Monitor hot water temperature readings and air conditioner temperature recordings. These facility failure had the potential for Resident 14 and Resident 87 to not be provided with a homelike and comfortable environment and had the potential for resident health problems and poor well-being of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident #31), had a comprehensive care plan that included interventions (actions) for the refusal of sitting upright while eating. This failure had the potential for Resident 31 to choke on food or liquids which can result in aspiration and possibly death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was monitoring for signs and symptoms of bleeding for a resident (Resident 53) who is on anticoagulant Eliquis (Medication that prevent or treat blood clots). This failure had the potential for Resident 53 to be unmonitored while on Eliquis, and have side effects of bleeding.

Inspectors wroteBased on interview and record review, facility failed to ensure: 1. There was a physician's justification for the use of antianxiety medication Xanax (a medication used to help reduce symptoms of aniety disorders) for use beyond 14 days in one of three selected residents for unnecessary medication review (Resident 53). 2. A physician signature was completed on informed consents for psychotherapeutic medications for one of 25 sampled residents (Resident 85). These failures had the potential for Resident 53 to be on unnecesary medication Xanax and the potential for Resident 85 not being informed of their medications and the potential side effects of the psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications per policy and procedure. This failure had the potential for expired medications to be administered to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician order of renal diet no added salt (NAS) order did not have a salt packet on the lunch tray for one of one sampled resident (Resident 82) who was on dialysis treatment. This failure had the potential for Resident 82 to have fluid retention for an already compromised condition (dialysis).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their cleaning policy and procedure (P&P) when: 1. A floor drain in the dry goods storage area and the floors were not maintained in a sanitary manner. 2. Two of two ice chests used to distribute ice to residents were not cleaned before and after use. These failures had the potential to cause food borne illness to a highly susceptible resident population.

Inspectors wrote2. During an observation on 2/4/25 at 10:21 a.m. Resident 49 was observed to be sleeping in bed with head slightly elevated, with nasal cannula tubing without label connected to oygen concentrator running at 2 liters per minute. There was an intravenous fluid IV 5% Dextrose running by gravity at 10-15 drops per minute, lines was observed to have label but without date and nurse's initial. During an interview on 2/4/25 at 10:30 a.m., certified nurse assistant (CNA6) confirmed there was no label on the oxygen tubing , and the label on the IV fluid did not have nurse's initial and there was no date making it impossible to know who and when the fluid was started. During the interview on 2/6/25 at 2:45 p.m. with the assistant director of nursing (ADON), ADON stated the tubings and IV fluids needed to be labeled dated and signed per policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights per policy and procedure, for one of 25 sampled residents (Resident 104) and one unsampled Resident (Resident 54) when: 1. Staff turned off Resident 54's call light and left the room, without addressing Resident 54's concern. 2. Call light was turned off by staff without meeting the request/needs for Resident 104. These facility failures had the potential for Resident 54 and Resident 104's needs to go unmet and/or result in a delay in care. 1. During an observation on 2/6/25, starting at 8:37 a.m., Resident 54's call light was observed on. An unidentified staff member (USM 1) entered Resident 54's room, turned off the call light, and left the room. During a concurrent observation and interview, on 2/6/25, at 9:00 a.m., with Resident 54, Resident 54's call light was activated for a second time. [...]

Inspectors wroteBased on observation, interview and Record Review the facility failed to ensure the safety of patients, staff and visitors when OXYGEN IN USE signs were not placed outside resident rooms per policy and procedure for 2 of 25 sampled residents (Resident 49 and Resident 57). This failure had the potential to result in an increase fire risk while oxygen is in use.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate and necessary information was communicated to the receiving home health agency (HHA) for a safe ,effective transition/continuance of care when the HHA was not informed of Resident 1's pressure ulcers and moisture associated skin damage (MASD) in the groin, scrotal, and perirectal areas. This failure resulted in Resident 1's responsible party not knowing of the skin condition, delaying the necessary skin treatment until HHA came and did the assessment finding a stage 2 ( skin opening on the first layer of skin).

Inspectors wroteBased on interview and medical record review, the facility failed to communicate necessary information to a resident, the resident representative, and to the continuing care provider at the time of an anticipated discharge to one of one resident (Resident 1). This failure had the potential to result in provision of inappropriate and untimely care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Late Entry documentation policy and procedure (P&P) met professional standards of timely documentation when P&P titled Late Entry, indicated in part There is not a time limit to writing a late entry. This resulted in a twelve-day delay of discharge planning notes to be available in the medical record of one of one resident (Resident 1). This failure has the potential for staff to add late entries without regards to timeframe or validity on the source of information and compromise timely continuity of care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete medical record in accordance with accepted professional standards and practices for one of one sampled resident (Resident 1), when Resident 1's medical record did not have discharge planning notes. This failure had the potential to cause miscommunication and confusion amongst members of the healthcare team and not implementing discharge care planning affecting the resident's continuity of care.

Inspectors wroteBased on interview and record review the facility failed to: 1. Document fluid intake accurately for 1 out of 2 sampled residents (Resident 1). 2. Document fluid intake accurately for 1 out of 2 sampled residents (Resident 2). This failure had potential to affect the hydration status of Resident 1 and may have contributed to Resident 1 being sent out to the emergency room (ER) for shortness of breath; and admitted to the hospital for sepsis and pneumonia. This failure had potential to affect the hydration status of Resident 2 and may have contributed to Resident 2 being sent out to the ER for altered mental status; and admitted to the hospital for pneumonia, urinary tract infection (UTI) and sepsis.

Inspectors wroteBased on interview and record review, the facility failed to ensure the family representative was notified of a change in condition for one of three sampled residents (Resident 1). This failure resulted in Resident 1's family member verbalizing feelings of mistrust and doubting the care the facility staff provided.

Inspectors wroteBased on record review and interview, the facility failed to ensure proper documentation of intake and output for one (resident 1) of two sampled residents, was completed as specified in the care plan. This failure could lead to facility staff being unaware of the resident 1's gastrointestinal functions, fluid balance, renal function, abnormal losses, and bowel movements that potentially contributed to resident 1's weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were properly following isolation precautions to prevent the spread of disease for two of 10 Sampled residents (Residents 552 and 96) when: 1. Staff member removed their used personal protective equipment (PPE) outside the isolation room ( supposed to be inside prior to exiting ) and did not perform hand hygiene after removing their PPE. 2. Facility policy and procedure related to the separation of clean and soiled items in Utility Rooms was not followed. 3. Expired medical supplies were not identified and removed from medical supply cabinets. 4. Remove contaminated isolation gown before exiting the resident room. These failures had the potential to transmit infectious microorganisms and increase the risk of infection for residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ventilation covers/panels were clean and free of dust when : 1. The ventilation cover and window tracks in room [ROOM NUMBER] was found with thick dust and dirt. 2. The ventilation cover outside room [ROOM NUMBER] was dirty. This failure have the potential for unclean and dirty air from the ventilations to circulate around which could cause respiratory infections inside the facility (residents, staff and visitors ).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two unsampled residents (Residents 84 and 100) assessements were accurate when : 1. The Minimum Data Set Assessment ((MDS- residents assessement ) Section K (Nutrition) for Resident 84 was not answered accurately and with missing infromation. This failure have the potential for an inaccurate assessment of the resident's nutrional and dietary status which can affect the plan of care . 2. For Resident 100, the Section A (discharge infromation) in the MDS have an inaccurate information. This failure have the potential for inappropriate discharge plans or information that can affect the resident's rights to admission or discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three unsampled residents (Resident 23) had accurate documentation in their medical record. For Resident 23, this failure resulted in an inaccurate representation of a change in their physical condition.