Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 St. John's Hospital Camarillo D/p Snf during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions experienced a significant weight loss of 14 percent over less than two months. Facility staff did not notify the physician of this change, as required by policy, resulting in a delay in altering the resident's treatment. Staff interviews and record reviews confirmed the lack of timely communication and documentation.
A resident with ALS, quadriplegia, and ileus experienced a significant weight loss over a two-month period. Although the care plan required monitoring for weight changes and consulting a dietitian as needed, no action was taken when the resident lost 14% of their body weight, and the RD was unaware of the change until the survey.
A resident with diabetes had a mismatch between the insulin dosage on the medication label and the physician's current order in the eMAR. Nursing staff identified the discrepancy but did not document notifying the pharmacy or sending the medication for relabeling, leaving the mislabeled insulin in use.
Residue buildup was observed inside the panels of an ice machine during inspection, with both the kitchen manager and Facility Maintenance Director acknowledging the issue and the need for filter replacement. Facility policy required regular cleaning, sanitizing, and filter changes, but these procedures were not followed as evidenced by the presence of residue.
A resident was observed lying in bed with an active extension cord containing six sockets and four bulky adapters mounted on the upper side rail, just 12 inches from their head. Maintenance and RN staff confirmed this setup was not permitted due to electrical and fire hazards, and facility policy prohibits such use of extension cords.
A resident with a tracheostomy was exposed to pathogens, resulting in maggots forming at the tracheostomy site. Despite regular tracheostomy care and equipment changes, the facility failed to prevent this exposure, highlighting a lapse in infection prevention and control measures.
A resident with complex medical needs reported feeling disliked and mistreated by staff, prompting notifications to various authorities. However, the facility failed to complete a required 5-day investigative report, as the incident was not classified as abuse, contrary to policy.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
Facility staff failed to notify the physician of a significant weight loss in a resident, as required by facility policy. The resident, who had diagnoses including Amyotrophic Lateral Sclerosis, quadriplegia, and ileus, experienced a 14 percent weight loss over less than two months. The weight record showed a drop from 69 kilograms to 59.9 kilograms, and the resident had refused to be weighed in the intervening month. This significant weight loss was not identified or communicated to the physician in a timely manner. Interviews with facility staff, including a registered dietitian, nurse informatics, a registered nurse, and a case manager, confirmed that there was no documentation of physician notification regarding the weight loss. The facility's policy required that a weight variance of five pounds or more be communicated to the physician and registered dietitian for further review. The lack of notification resulted in a delay in altering the resident's treatment.
Failure to Implement Care Plan Interventions for Significant Weight Loss
Penalty
Summary
The facility failed to implement care plan interventions for a resident with complex medical needs, including Amyotrophic Lateral Sclerosis, quadriplegia, and ileus. According to the facility's policy, all disciplines providing care are required to review and contribute to the resident's care plan, which should address services necessary to maintain the resident's highest practicable well-being. The resident's care plan for enteral feeding included monitoring for weight changes greater than 5% in one month and consulting a dietitian for caloric intake needs as needed. A review of the resident's records showed a significant weight loss from 69 kilograms to 59.9 kilograms over a period of less than two months. The resident refused to be weighed in one month, but the subsequent weight indicated a 14% loss. Despite this, no action was taken regarding the resident's weight loss, and the registered dietitian was not aware of the change until it was brought to their attention during the survey. This demonstrates that the care plan interventions, specifically monitoring and responding to significant weight changes, were not implemented as required.
Failure to Ensure Accurate Medication Labeling and Timely Pharmacy Notification
Penalty
Summary
A deficiency occurred when a resident with diabetes, complicated by retinopathy, was found to have a discrepancy between the insulin dosage instructions on the medication bottle and the physician's current order as reflected in the electronic Medication Administration Record (eMAR). The insulin bottle label instructed administration of 28 units at bedtime, while the eMAR indicated a current order of 25 units to be given twice daily. The resident's insulin order had been changed multiple times in recent weeks, but the medication label had not been updated to reflect the most recent physician's order. During medication administration, two licensed nurses confirmed the discrepancy and agreed that the pharmacy should be notified to correct the label. However, there was no documentation to show that the pharmacy had been informed or that the medication had been sent for relabeling. Facility policy requires that any discrepancy between the eMAR and medication label be resolved by checking the physician's order and sending the medication to the pharmacy for relabeling if necessary. This process was not followed, resulting in the continued presence of a mislabeled medication in the facility.
Ice Machine Maintenance Deficiency Due to Residue Buildup
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition when residue buildup was found inside the panels of the ice machine. During an inspection with the kitchen manager, a pink residue and dark streaks were observed on the ice machine panels using a white paper towel, and the kitchen manager confirmed that no residue should be present. Later, the Facility Maintenance Director also acknowledged the residue and stated that the filter needed to be changed. Review of the facility's undated Ice Machine Preventative Maintenance Procedure indicated that the facility had established procedures for cleaning, sanitizing, and replacing filters at least every six months or sooner depending on usage, but these procedures were not followed as evidenced by the observed residue.
Unsafe Placement of Extension Cord on Bed Side Rail
Penalty
Summary
A deficiency was identified when an extension cord with six sockets was found mounted on the right upper side rail of a resident's bed, approximately 12 inches from the resident's head while lying in bed. Four bulky adapter devices were plugged into the extension cord, and the power indicator light was on, indicating the cord was active. Maintenance staff confirmed that the extension cord was used for medical equipment and acknowledged that it should not be mounted on the side rail due to electrical and fire hazards. A registered nurse also stated that the extension cord should not be placed on the upper side rails because of safety concerns. Review of the facility's policy and procedure on extension cords indicated that extension cords should not be used as a substitute for fixed wiring or attached to building surfaces.
Infection Control Lapse Leads to Maggot Infestation
Penalty
Summary
The facility failed to prevent a resident from being exposed to pathogens carried by flies, resulting in the formation of maggots in the resident's tracheostomy site. The resident, who had a history of coronary artery disease, Type 2 diabetes mellitus, and depression, was admitted with a left middle cerebral artery infarct, expressive aphasia, and right hemiplegia. The maggots were discovered during a tracheostomy change, and the resident was subsequently treated for myiasis with hydrogen peroxide and ivermectin. Interviews with the Director of Nursing, a respiratory therapist, and a charge nurse revealed that tracheostomy care and equipment changes were performed every shift, and dressing changes were done as needed. Despite these measures, the maggots were found, indicating a lapse in infection prevention and control. The facility's infection prevention and control plan emphasized limiting unprotected exposure to pathogens and transmission of infections, but this incident demonstrated a failure to adhere to these protocols.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of abuse concerning a resident. The resident, who had a complex medical history including atrial fibrillation, metastatic cancer, and was receiving palliative care, expressed feelings of being disliked by the staff and a sense of undeserved treatment. Despite the resident's reluctance to name specific individuals, the concern was reported to the charge nurse, and notifications were made to law enforcement, the ombudsman, the California Department of Public Health (CDPH), Adult Protective Services (APS), and other relevant parties. However, during an interview with the Director of Sub-Acute (DSU), it was revealed that a 5-day investigative report was not completed as required by the facility's policy. The DSU was unaware of the requirement, and an email correspondence confirmed that the report was not considered necessary because the incident was not classified as an abuse case. This oversight was contrary to the facility's policy, which mandates reporting the results of all investigations in writing to the administrator and other officials, including the State Survey Agency, within five working days.
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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.
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Nursing homes near Camarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Healthcare Center Of Camarillo | 2 mi | ★★★★★ | 0 | 0 |
| Camarillo Healthcare Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Mary Health Of The Sick Convalescent & Nursing Hos | 6.3 mi | ★★★★★ | 0 | 0 |
| Oakview Skilled Nursing | 8 mi | ★★★★★ | 0 | 0 |
| Thousand Oaks Post Acute, Llc | 8.2 mi | ★★★★★ | 7 | 0 |
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