Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alta Healthcare Center Of Camarillo during CMS and state inspections, most recent first.
Two residents experienced significant delays in staff response to their call lights, with reported wait times of up to 45 minutes. Observations confirmed that staff did not respond promptly even when alerted by the call light system, and interviews with staff and administration acknowledged that such delays were not in line with facility policy.
Two residents did not have comprehensive care plans addressing their specific needs: one with multiple wounds, including pressure injuries and a traumatic leg wound, and another with bilateral bedrails in use since admission. Despite documentation of these conditions and interventions in medical records, no care plans were created as required by facility policy, a deficiency confirmed by the MDS coordinator, DON, and other staff.
A resident with psychosis and dementia was provided with bilateral bedrails without a documented assessment for risk of entrapment, as required by facility policy. Staff confirmed the absence of the assessment, and the bedrails had been in use since admission, with only staff able to operate them.
A resident with chronic pain and a history of spinal surgeries had orders for both Tylenol and Hydrocodone-acetaminophen written for the same pain level range, which was confirmed by nursing staff to be potentially confusing and could result in duplicate medication administration. The DON acknowledged the error and that the physician was not contacted to clarify the orders, contrary to facility policy.
A resident who required supplemental O2 and nebulizer treatments had both nasal cannula and nebulizer air tubing in use that were not labeled or dated, preventing staff from determining when the equipment should be replaced. An LN confirmed the missing information, which was not in accordance with facility policy requiring regular changes of such equipment.
A facility failed to develop a care plan for a resident with a suprapubic catheter within 48 hours of admission, as required by policy. The resident was admitted with conditions including septic shock and a suprapubic abscess. Despite these conditions, the baseline care plan did not include instructions for managing the catheter, confirmed by both the Treatment Nurse and the DON.
A facility failed to create an individualized care plan for a resident with a stage 4 pressure ulcer on the sacrum. The care plan included general interventions like a low air loss mattress and wound monitoring but was not person-centered. Interviews with staff confirmed the plan did not meet the resident's specific needs, despite the resident's history of septic shock and a triggered care area assessment for the ulcer.
A facility failed to report a resident's injuries of unknown origin to the State Agency and Ombudsman in a timely manner. The injuries were first noticed by the DSD and later confirmed by the Treatment Nurse, but were not reported until six days later. The resident's family had also brought the injuries to the facility's attention. The facility's policy requires timely reporting of such incidents, which was not adhered to in this case.
A resident was found with unreported injuries of unknown origin, including skin discoloration and an abrasion, which were discovered by the family. The facility staff were unaware of these injuries until informed by the family, and there was no documentation or reporting of the injuries as required by the facility's policies. This oversight indicated a deficiency in the facility's abuse prevention and reporting procedures.
The facility failed to maintain an effective infection prevention and control program, including cluttered hand washing areas, improper disposal of contaminated briefs, contamination of medication preparation areas, and improper handling of dirty laundry. These actions risked spreading harmful microorganisms.
The facility failed to ensure proper food storage, maintain an appropriate air gap for the dish machine drain, and follow high temperature dish machine guidelines. Raw ground hamburger was stored above pork cutlets, cooked pasta was not documented on the cool down log, and the dish machine's wash and rinse temperatures were below required levels.
A facility failed to develop and implement a care plan for a resident using a foley catheter. The catheter bag was found on the floor, and there was no doctor order or care plan in the resident's electronic medical record. The Infection Preventionist confirmed the oversight.
A resident's foley catheter bag was found on the floor, and there was no doctor order or care plan for the catheter. The facility's policy for catheter care was not followed, as confirmed by the Infection Preventionist.
The facility failed to document the quantity consumed of nutritional supplements for two residents, impacting the accuracy of nutrition assessments and the ability to monitor the effectiveness of interventions. Staff were not trained to document the quantity consumed, and supplements were often recorded as part of the overall meal intake without differentiation.
The facility failed to discard expired items in the medication storage room and treatment cart, and did not maintain proper temperature controls for medications and biologicals. Observations revealed expired items in a First Aid Kit and opened single-use items in the treatment cart. Additionally, the medication storage room and refrigerator temperatures were consistently out of the acceptable range.
The facility failed to implement its policy for foods brought in by family or visitors, as staff were unaware of the policy and there was no clear guidance on designated refrigerated storage. Interviews revealed a lack of training and contradictory practices regarding the storage of outside food.
The facility failed to maintain the confidentiality of resident medical records when the Discharge Summary (DS) of one resident was found attached to the DS of another resident. The Director of Nursing (DON) confirmed that the DS of the unsampled resident was mistakenly scanned into the clinical record of the sampled resident, violating the facility's policy on maintaining confidentiality of protected health information.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights for two of three sampled residents. One resident reported that it often took up to 45 minutes for staff to respond to her call light, which was her only means of communicating needs while in bed. During an observation, the call light was activated in her room and no staff responded for 15 minutes, despite six staff members being present at the nurse's station and visibly able to see the call light indicator. Staff interviews confirmed that the call light system alerts staff via monitors and hallway lights, and that they are expected to respond immediately. Another resident stated that staff did not answer call lights in a timely manner, sometimes waiting up to 45 minutes for a response. On one occasion, the resident had to physically approach staff at the nurse's station after receiving no response, and was told all nurses were on break. The facility's policy requires call lights to be answered within a reasonable time, which the administrator defined as within 3 to 10 minutes. The administrator agreed that response times of 30 to 45 minutes were not reasonable.
Failure to Develop and Implement Comprehensive Care Plans for Wound Management and Bedrail Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to wound care and the use of bedrails. For one resident, multiple wounds were identified upon admission, including a left heel deep tissue injury, a stage 2 sacral pressure injury, a right anterior leg traumatic wound, and a right heel skin fissure, along with skin discoloration on both upper and lower extremities. Despite these findings being documented in the resident's admission records, physician orders, and treatment administration records, there was no corresponding care plan addressing these wounds. The absence of a care plan was confirmed by both the MDS coordinator and the Director of Nursing during record reviews and interviews. Another resident was observed to have bilateral bedrails in use while in bed, a fact confirmed by staff and present since admission. However, there was no care plan in place to address the use of bedrails for this resident. This omission was acknowledged by both the Registered Nursing Supervisor and the Director of Nursing during interviews and record reviews. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, based on a thorough assessment and within seven days of the required comprehensive assessment. The lack of care plans for both wound management and bedrail use meant that the residents' specific care needs were not formally addressed or coordinated as required by facility policy. These failures were identified through direct observation, record review, and staff interviews, and were acknowledged by facility leadership.
Failure to Assess Entrapment Risk Prior to Bedrail Use
Penalty
Summary
The facility failed to assess the risk of entrapment prior to the use of bilateral bedrails for a resident who was admitted with diagnoses including unspecified psychosis, dementia with behavioral disturbance, and a need for assistance with personal care. During an observation, the resident's bed was found with small bilateral bedrails in the raised position. Record review and interviews with the registered nursing supervisor and the director of nursing confirmed that there was no completed assessment for risk of entrapment in the resident's health record. Further interviews revealed that the resident had the bedrails in place since admission, and only staff could operate the rails due to a locking mechanism. Review of the facility's policy indicated that an assessment for risk of entrapment should be completed when side rails are used for mobility or transfer. The lack of this assessment constituted a failure to follow facility policy and ensure resident safety regarding bedrail use.
Failure to Clarify Pain Medication Orders for a Resident
Penalty
Summary
The facility failed to ensure that pain medication orders for a resident with chronic back and leg pain were properly clarified with the physician regarding the appropriate pain level parameters for each medication. The resident, who had a history of multiple spinal surgeries and was diagnosed with spondylolisthesis and other musculoskeletal conditions, was observed to be alert and oriented while reporting ongoing pain. A review of the resident's Medication Administration Record revealed that both Tylenol and Hydrocodone-acetaminophen were ordered for the same pain level range (4-6), which could cause confusion for nursing staff regarding which medication to administer. A licensed nurse confirmed that the identical pain level parameters for both medications could lead to uncertainty in pain management. The Director of Nursing acknowledged that the orders were written in error and, without clarification from the physician, there was potential for the resident to receive duplicate medications. The facility's policy requires contacting the physician in the event of medication discrepancies, but this was not done in this case.
Failure to Label and Date Oxygen and Nebulizer Tubing
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident who was dependent on supplemental oxygen and nebulizer treatments. During an observation and interview, it was found that the resident's nasal cannula and nebulizer air tubing were not labeled or dated, making it impossible to determine when the equipment should be replaced. A licensed nurse confirmed the absence of labeling and dating on the tubing. Review of the facility's policy indicated that oxygen tubing and masks or cannulas should be changed weekly, and nebulizer tubing and delivery devices should be changed every 72 hours or as needed if soiled or contaminated. The lack of labeling and dating on the tubing was inconsistent with the facility's established procedures.
Failure to Develop Care Plan for Suprapubic Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident with a suprapubic catheter within 48 hours of admission, as required by their policy. The resident was admitted with serious conditions including septic shock, a suprapubic abscess, a urinary tract infection, and a pressure ulcer. Despite these conditions, the baseline care plan did not include instructions for managing the suprapubic catheter, which was confirmed by both the Treatment Nurse and the Director of Nursing. The facility's policy mandates that a baseline care plan be developed to address the immediate health and safety needs of residents within 48 hours of admission. This plan should include necessary healthcare information such as physician's orders and therapy services. However, the care plan for the resident in question did not include any information regarding the management of the suprapubic catheter, which was a critical aspect of the resident's care needs.
Failure to Individualize Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete an individualized care plan for a resident with a stage 4 pressure ulcer on the sacrum. The baseline care plan, which should have been developed within forty-eight hours of admission, was not person-centered and did not reflect the resident's specific needs for the sacral wound. The care plan included interventions such as the use of a low air loss mattress, wound treatment, and monitoring for infection, but it was not customized to the resident's condition. During interviews, the treatment nurse and the Director of Nursing acknowledged that the care plan was not individualized according to the resident's needs. The resident had a history of septic shock and a pressure ulcer, and the Minimum Data Set had triggered a care area assessment for the pressure ulcer. Despite these indicators, the care plan lacked the necessary person-centered approach, potentially leaving the resident's health, safety, and care needs unmet if their condition changed.
Delayed Reporting of Resident Injuries
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident to the State Agency and the Ombudsman in a timely manner. On May 8, the Director of Staff Development (DSD) noticed a skin abrasion on the resident's shoulder, cleaned it, and reported it during a morning clinical meeting. The Director of Nursing (DON) then delegated a skin check to the Treatment Nurse, who noted the abrasion and additional skin discoloration on the resident's chin. However, the facility did not report these injuries until May 14, six days after they were initially observed. The resident's family noticed the injuries on May 9 and informed the facility, but the facility still delayed reporting the incident. The facility's policy requires reporting any injury of unknown origin within 2 hours if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. The resident had a medical history including acute post-hemorrhagic anemia, gastrointestinal bleeding, and other conditions. The facility's delay in reporting the injuries was acknowledged by the Administrator, who admitted the report should have been made sooner.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse/Injuries of Unknown Origin policies and procedures when a resident was found with unreported injuries of unknown origin. The resident was observed with skin discoloration under the chin and on the left cheek, as well as an abrasion on the right shoulder. These injuries were discovered by the resident's responsible party and family, who were not notified of any incidents or falls that could have caused the injuries. The facility staff, including the administrator and Director of Nursing, were unaware of the injuries until they were brought to their attention by the family. The resident, who was admitted with multiple medical conditions including acute post-hemorrhagic anemia, gastrointestinal bleeding, and unspecified dementia, was noted to have intact skin upon admission. However, the facility's documentation did not reflect any changes in the resident's skin condition or any incidents that could have led to the injuries. The Director of Nursing and other staff members were unable to provide documentation or explanations for the injuries, indicating a lack of proper monitoring and reporting. The facility's policies require that any injury of unknown origin be reported to the appropriate authorities within a specified timeframe. However, in this case, the facility did not adhere to these policies, as there was no documentation of the injuries being reported or investigated. This oversight placed the resident at risk for further harm and highlighted a deficiency in the facility's abuse prevention and reporting procedures.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in several instances. In one case, a hand washing sink area in a resident's room requiring transmission-based precautions for C-DIFF was cluttered with a pink wash basin, preventing staff from washing their hands before exiting the room. The resident confirmed that staff did not wash their hands before leaving. The Infection Preventionist acknowledged the issue but cited limited storage space as a reason for the cluttered sink area. Additionally, C-DIFF contaminated briefs were improperly discarded in the same trash can used for doffing PPE, and the Infection Preventionist was observed compacting the trash with unprotected hands, further risking contamination. Another deficiency was observed with the medication cart, where a personal jacket, supply bag, and BP cuff were stored on the clean medication preparation area, contaminating it. A licensed nurse was seen placing a BP cuff from a contact isolation room on the clean PPE supply cart for cleaning, which was not in line with proper infection control practices. The facility's policy indicated that non-critical resident-care equipment should be dedicated to a single resident when transmission-based precautions are in effect, but this was not followed. Additional issues included an overflowing medication cart trash, expired water management test kits, and improper transportation of dirty laundry through the clean laundry area. The Director of Maintenance admitted awareness of the expired test kits but had not yet replaced them. A laundry worker was observed transporting dirty laundry through the clean laundry room, contrary to the facility's policy on handling soiled laundry. These failures collectively had the potential to spread harmful microorganisms to staff, residents, and visitors.
Food Safety and Equipment Compliance Issues
Penalty
Summary
The facility failed to ensure proper food storage in accordance with professional standards of food service safety. During an observation, a box of raw ground hamburger was found stored above pork cutlets in the walk-in refrigerator, contrary to the facility's policy and procedure which indicated that whole cuts of meat should be stored above ground meat. The Food Service Director (FSD) confirmed the improper storage and acknowledged the posted guidelines for proper food storage order were not followed. Additionally, cooked pasta, a Time-Temperature Control for Safety (TCS) food, was found in the walk-in refrigerator without documentation of the cool down process on the cool down log, as required by the facility's policy. The FSD and Kitchen Supervisor verified the omission and confirmed the pasta was intended for resident meals in both assisted living and skilled nursing sections of the facility. The facility's policy required recording food temperature every hour during the cooling process, which was not adhered to in this instance. The facility also failed to maintain 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. Observations revealed that the black plastic pipe used for drainage extended below the flood level rim of the floor sink drain, and the copper pipe was zip-tied to the black plastic pipe but not utilized for drainage. The Director of Maintenance (DOM) and FSD confirmed the lack of an appropriate air gap, which did not meet FDA food code guidelines requiring a one-inch air gap above the floor sink drain rim. An email communication with the Department of Health Care Access and Information (HCAI) also confirmed the requirement for an air gap and the prohibition of plastic pipes for drainage. Furthermore, the facility did not follow the high temperature dish machine (HTDM) manufacturer guidelines. The HTDM was observed to have wash and rinse temperatures below the required levels, with the wash temperature reaching only 138 degrees Fahrenheit and the rinse temperature reaching 158 degrees Fahrenheit, whereas the manufacturer's guidelines required a minimum wash temperature of 155 degrees Fahrenheit and a rinse temperature of 180 degrees Fahrenheit. The facility's policy mandated recording dish machine temperatures every shift and reporting any deviations to the Director of Food and Nutrition Services, but the Dishmachine Temp Log indicated multiple instances of temperatures below the required levels without appropriate action being taken. The FSD and Kitchen Manager confirmed the non-compliance with the manufacturer's guidelines and the facility's policy.
Failure to Develop and Implement Care Plan for Foley Catheter Use
Penalty
Summary
The facility failed to ensure that a care plan was developed and implemented for a resident using a foley catheter. During an observation, a foley catheter bag was found on the floor next to the resident's bed. Further review of the resident's electronic medical record revealed no doctor order or care plan for the foley catheter. The Infection Preventionist confirmed that the resident was not on the list of those with a foley catheter and acknowledged the presence of the catheter during a subsequent observation. The facility's policy requires the Care Planning/Interdisciplinary Team to develop an individualized comprehensive care plan for each resident, which was not done in this case.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate care and services to manage an indwelling catheter. During an observation, a foley catheter bag was found laying on the floor next to the resident's bed. The Infection Preventionist (IP) confirmed that there was no doctor order or care plan for the foley catheter in the resident's electronic medical record, and the resident was not listed as having a foley catheter. The facility's policy and procedure for catheter care, which includes keeping the catheter and tubing off the floor and ensuring the drainage bag is positioned lower than the bladder, was not followed.
Failure to Document Nutritional Supplement Consumption
Penalty
Summary
The facility failed to consistently document the quantity consumed of nutritional supplements for two residents, which impacted the accuracy of nutrition assessments and the ability to monitor the effectiveness of interventions. Resident 30, who was readmitted with severe protein-calorie malnutrition and a significant weight loss, had specific nutritional supplements ordered to meet their dietary needs. However, the staff did not document the quantity of these supplements consumed, and the supplements were not always offered or consumed as prescribed. The Restorative Nurse Assistant (RNA) and Licensed Nurse (LN) confirmed that they were not trained to document the quantity of nutritional supplements consumed, and the supplements were often recorded as part of the overall meal intake without differentiation. Resident 143, who appeared thin and was recommended nutritional supplements to meet their energy needs, also had issues with documentation. The Medication Administration Record (MAR) indicated that the supplements were administered, but there was no documentation of the quantity consumed. The Clinical Registered Dietitian (CRD) and other staff members confirmed that the lack of consistent and accurate documentation impeded the ability to monitor the effectiveness of the nutritional interventions. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Food Service Director (FSD) revealed that there was no system in place to quantify the consumption of nutritional supplements separately from the overall meal intake. The facility's policy and procedure on nutritional assessment required the dietitian to identify whether the resident's current intake met their nutritional needs, but the lack of proper documentation hindered this process. The staff had not received formal training on documenting the intake quantity of nutritional supplements, leading to inconsistencies and potential delays in revising interventions to meet the residents' nutritional needs.
Expired Items and Improper Temperature Controls in Medication Storage
Penalty
Summary
The facility failed to ensure that expired items in the medication storage room and treatment cart were discarded and not readily available for staff use. During an observation and interview, a sealed First Aid Kit (FAK) was found without a visible expiration date label, and upon opening, it was revealed to have expired in 2022. Additionally, the treatment cart contained opened, single-use items and steri-strips that should have been discarded. The facility's policies and procedures indicated that outdated or deteriorated medications should be immediately removed from stock, which was not followed in this instance. The facility also failed to maintain proper temperature controls for medications and biologicals stored in locked compartments. Observations revealed that the room temperature in the medication storage room was consistently out of the acceptable range, with readings of 78 and 79 degrees Fahrenheit, and the refrigerator temperature readings were 58 and 48 degrees Fahrenheit, both out of the required range. The facility's policies and procedures specified that medications requiring refrigeration should be kept between 36 and 46 degrees Fahrenheit, which was not adhered to, as evidenced by the temperature logs and staff interviews.
Failure to Implement Policy for Foods Brought by Family/Visitors
Penalty
Summary
The facility failed to ensure the implementation of its policy and procedure for foods brought in by family or visitors. Staff members were unaware of the policy, and there was no clear guidance on the location of a designated refrigerated area for storing such foods. During interviews, a Certified Nursing Assistant (CNA) stated that they did not know if family could bring in food to be stored for a resident and had not received training on this matter. Another CNA mentioned that the Food Service Director (FSD) checks the food first, and it gets stored in the kitchen. However, the FSD contradicted this by stating that the facility does not store outside food for residents. The Director of Marketing (DMK) confirmed that families sign the policy on admission, but staff are not educated on it. The Director of Staff Development (DSD) also confirmed that there is no formal training on foods brought from home. The facility's policy, dated 11/2017, indicated that food brought by family or visitors should be labeled and stored in a manner distinguishable from facility-prepared food, with perishable foods stored in resealable containers with tightly fitting lids in a refrigerator. The containers should be labeled with the resident's name, the item, and the use-by date. The lack of staff awareness and training on this policy led to the deficiency, potentially denying residents, family, and visitors their right to store outside food safely for later consumption.
Breach of Resident Confidentiality in Medical Records
Penalty
Summary
The facility failed to ensure resident medical records were kept confidential when the Discharge Summary (DS) of one unsampled resident was found attached to the DS of one sampled resident. This breach occurred during a review of the clinical record of the sampled resident, where a document titled Discharge Summary under the unsampled resident's name was found attached to the sampled resident's DS. During a concurrent interview and record review with the Director of Nursing (DON), it was confirmed that the DS of the unsampled resident was mistakenly scanned into the clinical record of the sampled resident. The facility's policy and procedure on the release of information indicated that the confidentiality of each resident's personal and protected health information must be maintained, which was not adhered to in this instance.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 217 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Camarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. John's Hospital Camarillo D/p Snf | 2 mi | ★★★★★ | 0 | 0 |
| Camarillo Healthcare Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Mary Health Of The Sick Convalescent & Nursing Hos | 4.4 mi | ★★★★★ | 0 | 0 |
| Oakview Skilled Nursing | 6.3 mi | ★★★★★ | 0 | 0 |
| Thousand Oaks Post Acute, Llc | 6.3 mi | ★★★★★ | 7 | 0 |
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