Inspection Reports for
Camarillo Senior Living

The complaint investigation found substantiated delays in call light response times, with residents reporting waits up to 45 minutes and staff acknowledging unreasonable response times.

The facility failed to ensure timely response to call lights for 2 of 3 sampled residents, with delays up to 45 minutes. The facility's policy requires call lights to be answered within 3 to 10 minutes, but observations and interviews confirmed longer delays.

The investigation was complaint-driven, focusing on care plan deficiencies, bedrail safety assessments, medication order clarity, and infection control practices. The complaints were substantiated with findings of minimal harm or potential for harm.

The facility failed to develop and implement complete care plans for residents with pressure injuries and bedrail use, failed to assess entrapment risk before using bedrails, had unclear pain medication orders risking duplicate dosing, and did not label or date oxygen and nebulizer tubing, risking infection transmission.

During the walkthrough, a video camera was observed in the bedrooms of two residents without an approved exception request on file allowing the use of cameras inside resident rooms. A citation was initially issued but later amended to reflect no citation issued.

The complaint investigation was substantiated for delayed staff response to call buttons, with evidence including interviews and review of 49 calls with response times exceeding 10 minutes, some up to over 30 minutes. The complaint regarding staff COVID positive status was unsubstantiated.

The investigation substantiated that staff response times to call buttons were often delayed beyond the facility policy of 5 to 10 minutes, with some responses taking over 30 minutes, posing a potential health and safety risk. The allegation regarding staff working while COVID positive was unsubstantiated due to lack of evidence and no active outbreak at the time.

The visit was triggered by complaint #29-AS-20240429161933. The deficiency related to failure to report a serious incident was substantiated during the investigation.

The facility failed to submit a Special Incident Report (SIR) to Community Care Licensing to notify of Resident #1's hospitalization on 04/23/2024 and did not notify the resident's physician or the Department of the resident's change of condition prior to hospitalization.

The complaint was substantiated. Allegations included neglect leading to multiple pressure injuries, failure to address a resident's change in condition timely, unmet hygiene and clothing needs, and bathroom disrepair. Other allegations such as feeding, isolation, and facility cleanliness were unsubstantiated.

The investigation substantiated neglect and lack of care resulting in a resident sustaining multiple pressure injuries, failure to address a resident's change in condition timely, unmet hygiene and clothing needs, and bathroom disrepair. Other allegations such as feeding, isolation, and facility cleanliness were unsubstantiated.

The facility failed to develop and implement individualized care plans for Resident 1's suprapubic catheter and sacral pressure ulcer. These deficiencies had the potential to delay care and result in unmet health and safety needs.

The facility was generally found to be in compliance with health and safety regulations, with clean and well-maintained resident rooms and common areas. However, deficiencies were noted in employee training and medication record-keeping.

The complaint investigation found that the facility delayed reporting injuries of unknown origin on Resident 1 to the State Agency and Ombudsman. The report was submitted on 5/14/24, six days after the injuries were first noted on 5/8/24. The family notified the facility on 5/9/24, but the facility did not report until 5/14/24. The complaint was substantiated.

The facility failed to report injuries of unknown origin on Resident 1 within the required timeframe, delaying notification by six days. Observations and interviews confirmed the presence of skin abrasions and discolorations that were not promptly reported, violating facility policy and regulatory requirements.

The complaint investigation was substantiated as the facility failed to report and document injuries of unknown origin on Resident 1, and the responsible party was not notified in a timely manner.

The facility failed to implement its Abuse/Injuries of Unknown Origin policies when Resident 1 was found with unreported injuries including an abrasion on the right shoulder and bruises on the chin and left cheek. Documentation and notification of these injuries were lacking, and staff were unaware of the injuries until family brought them to attention.

The facility failed to develop and implement complete care plans for residents with foley catheters, ensure appropriate catheter care, consistently document nutritional supplement consumption, maintain proper medication storage and temperature controls, follow food safety standards, implement policies for foods brought by visitors, safeguard resident medical records confidentiality, and maintain an effective infection prevention and control program.

The facility failed to provide written notice to the responsible party before moving Resident 1 to another room, violating the resident's right to share a room with a spouse or roommate of choice and receive advance notice of room changes.

The complaint investigation found that the facility did not notify Resident 1's family member or second contact person of the resident's change in condition and unplanned transfer to the ER. The Director of Nursing was unable to confirm notification. The facility policy requires notification for significant changes and hospital transfers.

The facility failed to ensure that the family member or second contact person of Resident 1 was notified appropriately and timely about the resident's severe right hip pain and unplanned transfer to the emergency room. The Director of Nursing could not confirm whether notification was made as required by facility policy.

The facility's infection control policies were found adequate. A deficiency was cited for two staff members who assist residents with activities of daily living lacking first aid training.

The facility was generally in compliance with regulations, with clean and well-maintained resident rooms and common areas. However, two deficiencies were cited related to an unlocked storage closet containing used sharps and failure to notify the Department in writing of a new Executive Director within 30 days.

The facility failed to ensure proper labeling and storage of medications, maintain sanitary conditions of the ice machine, and implement proper hand hygiene during an active Clostridium difficile outbreak. These deficiencies posed potential harm to residents through unsafe medication use, increased risk of foodborne illness, and potential mass infection outbreak.

The facility failed to implement a baseline care plan in a timely manner for one resident at risk of seizures due to a brain infection after surgery. The care plan was initiated 25 days after admission, which was also the resident's discharge date, indicating a delay in meeting immediate care needs.

The investigation was triggered by an alleged staff to resident abuse incident involving Resident 1. The finding was substantiated as the facility failed to develop an appropriate care plan after the incident.

The facility failed to develop a person-centered care plan focused on safety and protection for Resident 1 after the alleged abuse incident. This failure potentially impacted the resident's psychosocial well-being and quality of life.

The complaint investigation found that the facility did not administer the prescribed medication rifaximin to Resident 1 as ordered, with the failure substantiated by medication administration records and staff interviews.

The facility failed to administer the prescribed medication rifaximin to Resident 1 on multiple dates due to the medication not being onsite, which had the potential to cause negative outcomes. The facility's policy requires medications to be administered according to physician orders without unnecessary interruptions.

The investigation was complaint-driven, focusing on allegations that the facility failed to accurately record MDS data and implement care plans for pressure ulcer prevention and treatment in three residents. The complaint was substantiated based on interviews, record reviews, and policy evaluations.

The facility failed to ensure accurate MDS coding for turning/repositioning programs and nutrition interventions for three residents, resulting in inaccurate care documentation. Additionally, care plans lacked specific turning/repositioning frequency, and no documentation was recorded to monitor or evaluate these interventions. The facility also failed to implement the wound care physician's plan for a low air loss mattress and did not monitor turning/repositioning interventions, leading to worsening pressure ulcers in residents.

The complaint investigation was initiated based on allegations received on 07/08/2021. The allegation that the facility did not address a resident's medical condition was found unsubstantiated. The allegation that the facility did not meet a resident's dietary needs was substantiated.

The allegation regarding the facility not addressing a resident's medical condition was unsubstantiated due to insufficient evidence. The allegation that the facility was not meeting a resident's dietary needs was substantiated, with findings that the facility failed to provide physician-ordered modified diets and dining staff were unaware of these orders.

The inspection found unlocked supply closets and laundry room doors in the Memory Care unit containing potentially harmful items such as shampoo, body wash, laundry detergent, and Listerine, posing an immediate health risk to residents with dementia.