Other·July 19, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during a Standard Abbreviated Survey for investigation of a complaint. Complaint: CA00535485 - Substantiated Representing the Department: HFEN 22426 The inspection was limited to the investigation of the complaint, and does not reflect the findings of a full inspection of the facility.

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 08/01/2017 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 41MT11 Facility ID: CA050000070 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555701 (X3) DATE SURVEY COMPLETED 07/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIMI HEALTHCARE CENTER 5270 E Los Angeles Ave Simi Valley, CA 93063 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to permit Resident 1 to return to the facility after Resident 1 was transferred to an acute care hospital on 1/18/17, for evaluation and treatment due to "right eye blood shot." This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma Resident 1. Findings: A review of the facility's admission policy on 5/16/17 under "Admission, Transfer and Discharge" indicated "the facility must permit each resident to remain in the facility, and not transfer or discharge unlessi) The transfer or discharge is necessary for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 41MT11 Facility ID: CA050000070 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555701 (X3) DATE SURVEY COMPLETED 07/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIMI HEALTHCARE CENTER 5270 E Los Angeles Ave Simi Valley, CA 93063 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's welfare, and the resident's needs cannot be met in the facility; ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; iii) The safety of individuals in the facility is endangered; iv) The health of individuals in the facility would otherwise be endangered; v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to the facility, the facility may charge a resident only allowable charges under Medicaid; or vi) The facility ceases to operate." Record review on 5/16/17 indicated Resident 1 was admitted to the facility during August 2016 with diagnoses including atrial fibrillation (irregular heart beat), depression, and stroke. The facility's Resident Transfer Record, dated 1/18/17, indicated, Resident 1 was transferred to an acute care hospital (ER) due to "Right eye blood shot." A review of the acute care hospital's ER Physician Note, dated 1/18/17 at 9:48 p.m., indicated it was the physician's intent was to discharge Resident 1 to the facility, "however the administrators they are refusing to take the patient (Resident 1) back. The note also indicated a "Charge Nurse spoke to the facility at length." Review of the ER nurses' note, dated 1/18/17 at 10:39 p.m., indicated a nurse spoke with the facility, and the facility "stated they did not want to accept the resident back." The ER nurse informed the facility staff they needed to work FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 41MT11 Facility ID: CA050000070 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555701 (X3) DATE SURVEY COMPLETED 07/19/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIMI HEALTHCARE CENTER 5270 E Los Angeles Ave Simi Valley, CA 93063 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that out with the daughter because the Resident 1 was cleared for discharge from the acute care hospital. Review of another ER nurses' note, dated 1/18/17 at 11:01 p.m., indicated the nurse spoke with the facility's administrator, who stated if the hospital ER send Resident 1 to the facility, Resident 1 will not be permitted admission. Further review of the acute care hospital's clinical record for Resident 1 on 1/31/17 revealed a Case Manager/Social Worker note, dated 1/19/17 at 1:45 p.m., indicated the Case Manager spoke with the facility, and the facility refused to permit Resident 1 to return to the facility. Another Case Manager/Social Worker note, dated 1/20/17 at 2:00 p.m., indicated Case Manager spoke with facility's Administrator who indicated he will not accept Resident 1 back to the facility. During an interview on 5/16/17 at 2:30 p.m., the facility's Administrator confirmed denying Resident 1 readmission to the facility. The Administrator stated "the management team made an executive decision not to permit the resident (Resident 1) back to the facility." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 41MT11 Facility ID: CA050000070 If continuation sheet 4 of 4