Simi Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep a resident free from hazards and provide the necessary monitoring and supervision for a resident with known diagnoses with Claustrophobia (an anxiety disorder characterized by an intense, irrational fear of confined or enclosed spaces) when a resident eloped from facility through the room window without staff notification for one of three sampled residents (Resident 1). This failure placed the resident at risk for serious injury and harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) by failing to ensure a physician signature was obtained for Resident 1's, Physician Orders for Life-Sustaining Treatment (POLST), form dated 10/24/25. This failure resulted in conflicting medical records and delayed timely emergency medical decision-making during a change in Resident 1's condition, including during the emergency response preceding the resident's death. During a review of the Resident 1's admission Record (AR), the AR indicated Resident 1 was an [AGE] year-old female, initially admitted to facility on 06/18/2020 with the last re-admission date of 06/16/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a full time Director of Food and Nutrition Services (DFN) who met the federal and state's education qualification requirements to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the part-time contracted Registered Dietitian (RD) provided sufficient frequently scheduled consultation to the DFN to include overseeing kitchen sanitation, food preparation, meal service and food storage. This failure that had the potential to place 69 of 69 residents who received meals from the kitchen at an increased risk of foodborne illness and/or unmet nutritional needs. During an interview on 08/4/25 at 9 a.m. with Dietary Aide (DA) in the kitchen, DA stated they had a full-time dietary manager and there was an assistant manager, but both were off today. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitation and food safety in the kitchen when: 1. Multiple opened and prepared food items were unlabeled or undated in the reach-in-freezer, walk-in refrigerator and dry storage areas. 2. The walk-in refrigerator and dry storage room were not maintained in clean and sanitary condition, as evidenced by cracked fixtures, holes in the ceiling, debris on the floor and shelving, dust built up on fans and pipes, and visible black residue on walls. 3. Clean food service equipment was not handled and stored in a sanitary manner as evidenced by designating visibly soiled equipment as clean and handling clean rack of dishes with unwashed hands. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that1. All medications stored in the facility's drug storage areas were available for use and had not expired.2. Pharmaceutical E-Kits (Emergency Kits containing antibiotics, sedatives, pain medications in limited quantities intended for use when supplies are limited) were replaced after opening. These failures had the potential to affect the efficacy and availability of medications administered to residents.

Inspectors wroteBased on interview, and record review, the facility failed to provide monthly medication reviews for the months of May, June, and July 2025 for 4 of 19 sampled residents (Residents 7, 101, 2, and 12). This failure has the potential to result in residents having side effects or adverse reactions to medications and the attending physician not to be notified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. Medications were stored in accordance with manufacturers' storage specifications and/or the facility's policies and procedures (P&P).2. Medication room storage temperatures were continually monitored. These failures had the potential to affect the efficacy and availability of medications administered to residents and alter the delivery of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the observance of proper infection control practices for five of six sampled residents (Residents 5, 6,18, 20, and 54) and 12 unsampled residents (Residents 16, 21, 27, 39, 45, 48, 53, 74, 80, 92, 95, 100, and 106). This failure had the potential to result in infectious outbreaks compromising the health, safety and welfare of residents, visitors, staff and the public.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide breakfast at a later time than the routinely scheduled breakfast time for 1 of 69 residents (Resident 33) when Resident 33 requested breakfast be delivered between 9-9:30 a.m. This failure resulted in Resident 33's food being cold and unpalatable by the time the resident woke up around 9-9:30 a.m. and had the potential to diminish Resident 33's autonomy and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a gradual dose reduction for psychotropic medications for 1 of 19 sampled residents (Resident 101). This failure had the potential to result in Resident 101 receiving unnecessary medication and having complications from the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) documentation in their medical record was accurate when wrongfully documenting that the resident is not currently on an antibiotic medication. This failure has the potential to create confusion upon health care team reviewing documentation and deciding the next best course of treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of six sampled residents (Resident 18) was assessed for a PASARR (Pre-admission Screening and Resident Review - a Federal Program that ensures individuals with serious mental illness, intellectual disabilities, or related conditions are placed in nursing facilities and receive necessary services) after a COC (change of condition) for mental illness. This failure resulted in Resident 18 not being properly evaluated and possibly referred to receiving care and services in the most integrated setting appropriate to their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) care plan was implemented when Resident 1 had a change in condition and the monitoring was not documented in the residents medical record. This failure has the potential for changes in residents status to be missed and delay in proper medical intervention. During a review of Resident 1's Progress Notes dated 7/15/25, the Progress Notes indicated, Resident 1 had a change in condition (CIC) by pulling out his Gastrostomy Tube (G-tube, a feeding tube inserted through the abdominal wall directly into the stomach) during the day shift. The G-tube was reinserted at bedside on 7/15/25 during the p.m. shift. Resident 1 was placed on 72 hour CIC monitoring. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 28), received proper treatment to maintain their vision. This failure resulted in a decline in Resident 28's vision and had the potential to result in adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the availability of a reserve emergency tracheostomy tube (a curved, hollow tube inserted into the trachea [windpipe] to maintain an open airway) at bedside for one of six sampled residents (Resident 18). This failure had the potential to result in life threatening complications.

Inspectors wroteBased on observation, interview, and manufacturer's instructions, the facility failed to have sufficient, competent dietary support staff to ensure sanitation and food safety in the kitchen when: sanitizing solution was not used consistently with the Environmental Protection Agency guidelines. This failure had the potential for the chemical sanitizers to be harmful and toxic to the residents. During a concurrent observation and interview on 8/4/25 at 2:55 p.m. with the Dietary Worker (DW) in the kitchen, DW demonstrated how to test the sanitizing solution located in a red bucket. DW placed a Hydrion QT [quaternary ammonium compound]-10 quaternary test strip into the prepared sanitizing solution located in the red bucket and immediately removed it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a vegetarian menu planned in advance with evaluation of nutritional adequacy for kitchen staff to follow for two of two sampled residents (Residents 23 and 38) to meet the resident's choices and special dietary needs in accordance with established national guidelines. This failure resulted in a lack of implementation of vegetarian menus with variety, standardized vegetarian recipes and evaluation for nutritional adequacy which had the potential to lead to deficits in some nutrients, vitamins and minerals adversely affecting residents' nutritional and/or medical status. During a concurrent observation and interview on 8/5/25 at 10:25 a.m. with Dietary Aide (DA) in the kitchen, DA was preparing cheese sandwiches with two yellow colored cheese slices. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a vegetarian alternate meal of similar nutritive value for one of one sampled resident (Resident 23) who received a cheese sandwich that provided 5 grams of protein versus the planned main entree of Hawaiian chicken provided approximately 21 grams of protein. Facility failure to have standardized vegetarian recipes and planned vegetarian alternatives to ensure nutritional adequacy placed residents who chose vegetarian diets at risk of decreased nutrient intake, decreased variety of choices and diminished quality of life. During a concurrent observation and interview on 8/5/25 at 10:25 a.m. with Dietary Aide (DA) in the kitchen, DA was preparing cheese sandwiches with two yellow colored cheese slices per sandwich. DA stated there was no recipe to follow to instruct on how to prepare the cheese sandwich. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physical and occupational therapy for one of one sampled resident (Resident 101). This failure resulted in Resident 101 not receiving therapy and had the potential for the resident to not achieve their highest practicable level of function.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were accurate and complete by not having a physician order for code status in place for 2 of 19 sampled residents, (Residents 7 and 2). This facility failure had the potential to result in residents receiving treatment inconsistent with their expressed wishes, including unwanted resuscitation in the event of cardiopulmonary arrest (heart suddenly stops pumping blood effectively, leading to a loss of consciousness and breathing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for 2 of 19 sampled residents (Residents 7 and Resident 2). This failure prevented residents from calling for assistance and had the potential for delays in receiving needed care. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/20, the P&P indicated, The purpose of this policy is to respond to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. During an observation on 8/4/25 at 10:10 a.m. Resident 7 was observed lying in bed with the call light clipped and secured near the electrical outlet, out of reach of Resident 7. During a concurrent observation and interview on 8/4/25 at 10:18 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer ordered morning medications, including sliding scale insulin, and failed to monitor blood glucose levels as ordered for one of seven sampled residents (Resident 1). This failure resulted in Resident 1 experiencing critically high blood glucose levels, becoming unresponsive, requiring emergency medical treatment, and ultimately dying following transfer to an acute care hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure 24-hour licensed nursing staff coverage in the skilled nursing unit as required to meet the nursing related care needs for a total census of 73 Residents. This failure resulted in a five-hour period without licensed nurse coverage in the skilled nursing unit, placing residents at risk for delayed assessments, interventions, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer prescribe insulin doses and monitor blood glucose levels as ordered for five of seven sampled residents (Residents 2, 3, 4, 5, and 6). These failures resulted in missed critical diabetic treatment and placed all five residents at risk for serious complications, including hyperglycemic, hyperglycemia, and acute changes in condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse (LN ) was trained and competent in using the electronic Point Click Care (PCC, electronic health record system) for documentation and care coordination. This failure has the potential to result in incomplete, delayed, or missing documentation of resident care, placing the resident at risk for unmet care needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a person-centered care plan for one of two sampled residents (Resident 1) who was admitted with skin discoloration. This failure had the potential for Resident 1 to have further skin issues not assessed and treated.

Inspectors wroteBased on record review and interview, the facility failed to ensure a fall risk re-evaluation was done on readmission to the facility for one of one sampled resident (Resident 1) with prior history of falls. This failure had the potential to result in further fall incidents.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of three sampled residents (Resident 1) after Resident 1 fell while at the facility and sustained injuries. This facility failure placed Resident 1 at a higher risk for fall and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures to one of three residents (Resident 1) when: 1. Medications were left unsecured and unsupervised. 2. Medications were administered by a Licensed Nurse (LN 3) that LN 2 had prepared without verifying doctor's orders. LN 2 signed the Medication Administration Record (MAR). 3. Doctor's order was not followed during administration of a medication. 4. Medication was administered through a gastrostomy tube without verification of placement. 5. Oxygen tubing was not labelled. These facility failures had the potential for Resident 1 to experience negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for two of two sampled residents (Residents 1 and 2) to the local law enforcement per federal regulation. This failure resulted in suspected abuse to go unreported and the local police department unable to perform an investigation. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated, Investigate and report any allegations within timeframes required by federal requirements. During a review of the facility's investigation report titled, Resident Abuse Investigation Report Form (IR), dated 12/23/2024, the IR indicated, the incident was not reported to the local police department. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used to let staff know assistance is needed) was in reach for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive needed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen and food storage sanitation was maintained when: 1. A pair of used gloves was observed on the food preparation counter. 2. One of two ice machines was not properly maintained according to manufacturer's guidelines. 3. A kitchen staff (KS 1) was observed transferring food trays, wiping down stove top and counters with ungloved hands and not performing hand hygiene in between these activities. These failures had the potential to result in an increased risk of food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins) to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 443) was free from physical restraints. This facility failure had the potential to violate Resident 443's rights and lead to psychosocial and physical harm.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities) information was accurate for two of two sampled residents (Residents 8 and 13) when: 1. Resident 8's MDS indicated, the resident was not taking anticoagulant medication (medications that reduce the blood's ability to clot). 2. Resident 13's MDS indicated, the resident was comatose (a state of unconsciousness). These failures resulted in inaccurate MDS assessments for Residents 8 and 13, and for the residents to potentially receive inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for two of eight sampled residents (Residents 79 and 13) when: 1. Resident 79's care plan intervention for risk for shortness of breath was not followed. 2. Resident 13 did not have a care plan to address their hearing needs. These failures had the potential for Residents 79 and 13 to not receive the appropriate care and services, based on problem areas identified during admission and current health issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 43) received adequate nutrition when a recommendation by the Registered Dietitian to increase gastrostomy tube feedings was not ordered and implemented. This failure resulted in the resident having significant weight loss and the potential for delayed healing of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Physician Orders for Life- Sustaining Treatment (POLST - a form that communicates a person's wishes for healthcare treatment during a medical emergency) was signed by the physician for one of six sampled residents (Resident 68). This failure had the potential for Resident 68 to not receive his wishes during a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an optimal temperature was maintained in the medication storage refrigerator in Nurse Station One. This failure had the potential to result in refrigerated medications being less effective.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified dietary supervisor, in the absence of a full-time registered dietitian, to oversee its kitchen and food service operations. This failure had the potential to result in residents not receiving correct diets and increased risk of food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites or toxins) to the residents due to lack of proper staff education and training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures on storing oxygen therapy equipment were maintained for two of five sampled residents (Residents 83 and 57). These failures had the potential to result in the transmission of infectious microorganisms and increase the risk of respiratory infection of residents, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation indicating it had offered or explained the risks and benefits of a Covid -19 vaccination, for one of five sampled residents (Resident 443). This facility failure had the potential to lead to negative outcomes for Resident 443.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a call light was within reach for one unsampled resident (Resident 12). This facility failure had the potential for Resident 12's needs to go unmet and/or result in a delay in care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment for three unsampled residents (Residents 9, 12, and 14). This failure had the potential to negatively impact residents psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed for one of two sampled residents (Resident 33) who was assessed as high risk for falls. This failure had the potential to result in further fall incidents for this resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity when the facility: 1. Failed to allow Resident 2 to self-determine shower times. 2. Did not provide privacy to Resident 2 when getting undressed. These failures had the potential for psychosocial harm to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to monitor any change in behavior for one of two residents (Resident 2) following an allegation of staff to resident mistreatment. This failure had the potential for Resident 2 to have a psychosocial change that would go untreated.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 2) when a Shower Day Skin Inspection (a dated and signed record of shower/bath given with details to grooming performed and skin inspection/changes) not accounted for on a shower provided on 5/4/24. This failure had the potential to result in resident not receiving proper treatment if there was a change in skin status.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for one resident (Resident 1) when it was documented a medication was administered twice when in fact it was not. This failure resulted with Resident 1's medication administration record (MAR) to reflect inaccurate documentation of a prescribed medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included the Resident Representative's (RP) preferences for one of two sampled residents (Resident 1). This failure had the potential to result in negatively impacting the resident's quality of life, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 64) call light was within resident reach. This failure had the potential for resident needs not being met.

Inspectors wroteBased on observation and interview, the facility failed to maintain an overbed light fixture for one of twenty sampled residents (Resident 88). This failure had a potential to affect the safety of Resident 88.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty sampled residents (Resident 60) was free from any form of restraint. This failure had the potential to result in decline in range of motion and injury to the area being restrained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan for oxygent treatment was followed for one of twenty residents (Resident 62). This failure had a potential for Resident 62 to not recieve appropriate amounts of oxgen.

Inspectors wroteBased on interview and record review, the facility failed to ensure the respiratory care plans of two of twenty sampled residents (Resident 33 and Resident 53), were reviewed and updated, to reflect the residents' current health status and respiratory needs. This failure had the potential to place the residents at risk for unrecognized changes of condition, which may delay the implementation of care interventions and cause harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure quality control tests (tests performed to ensure accuracy of the blood glucose [sugar in the blood] monitor machine) were performed on two of two sampled glucometer (measures blood glucose level) machines. This failure had the potential to not accurately measure residents' blood glucose levels, that can lead to illness, and complications with diabetes (a group of diseases that result in too much sugar in the blood).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nail care for one sampled resident (Resident 15). This failure had the potential to harbor microorganisms (bacteria, virus, or fungus) and for infection to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing for two of twenty sampled residents (Resident 62 and Resident 88) were dated. These failures had the potential for cross-contamination to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper labeling and storage of drugs on three of three sampled medication carts. This failure had the potential to not ensure accurate dose and safe medication administration to residents.