Simi Healthcare Center

In the surveyor’s words

From the most serious findings on record at Simi Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 30, 2025

  Based 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. Findings: During a review of Resident 1's admission Record (AR), dated 6/3/25, the AR indicated, Resident 1 was admitted in the facility on 4/24/25 with diagnoses including, diabetes mellitus type 1 (DM 1, condition in which the body cannot produce insulin or produces so little that insulin therapy is required to survive), Parkinson's disease… […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure the observance of proper sanitation and food handling practices when the Dietary Manager (DM) and 3 Dietary Staff (DS1, DS2, DS3), failed to wear a beard restraint during food handling. This failure had the potential to result in foodborne illnesses among the residents. During a concurrent observation and interview on 8/3/26 at 11:55 AM with the DM in the kitchen during lunch food service, the DM, DS1, DS2, and DS3 were all observed with facial hair present and no beard restraint used. The DM agreed that all facial hair should be covered by a beard restraint in the kitchen to prevent potential contamination of the food. […]

• No harm, potential for more than minimal, widespreadF801Aug 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF755Aug 7, 2025

  Based 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. Findings: 1. During a review of the facility’s policy and procedure (P&P) titled, “Storage of Medications,” dated 1/2025, the P&P indicated, “Procedures…n. […]