Health inspection·January 22, 2026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Resident 1's diagnoses included, fracture (break) of left humerus (upper arm), acute and chronic respiratory failure with hypoxia (a condition in which the lungs are unable to deliver enough oxygen into the blood, occurring both suddenly and over time, resulting in dangerously low oxygen levels), Interstitial Pulmonary Disease (a group of lung disorders that cause scarring and stiffness of the lungs, making breathing difficult and reducing oxygen exchange, Pneumonia (a lung infection causing inflammation and fluid in the lungs, which can worsen breathing and oxygenation), Chronic Kidney Disease with Hypertensive Heart Disease and Heart Failure (long-standing kidney disease combined with high blood pressure and heart failure, which can cause fluid buildup in the lungs and worsen breathing). During a review of Resident 1's Progress Note (PN), dated 11/26/25 at 2:32 p.m., the PN indicated, at 7:45 - 8 a.m., CNA delivered breakfast tray with feeding assist and resident tolerating few bites and sips of juice. Approx. 8:15 - 8:20 a.m. nurse called to room by RNA (Restorative Nurse Aide) who stated, resident unresponsive. 911 called.During a review of the Emergency Medical Services (EMS), report dated 11/26/25 at 8:28 a.m., the Report indicated, Arrived on scene to a skilled nursing facility to find an 84 yo female patient lying supine in bed pulseless and apneic. Arrest (cardiac) was witnessed and story was unclear. Facility staff reported conflicting information. Last known well was approximately 30 minutes prior to EMS arrival. Basic Life Support (BLS) measures were initiated initially due to uncertainty regarding Do Not Resuscitate (DNR) status. Patient had 2 DNR forms both marked DNR but the most recent form not being signed. Family was contacted by the skilled nursing facility. Daughter was reached and stated she wants full resuscitation measures to be performed.During a review of Resident 1's POLST forms, the POLST forms indicated, POLST dated 10/05/2023 had the following checked, DNR, selective treatment and trial period of artificial nutrition and signed by the physician on 10/6/23. POLST dated 10/25/2024 had the following checked, DNR, selective treatment and no artificial means of nutrition. There was no physician signature on the form.During a review of Resident 1's Order Summary Report (OSR), dated 11/25/25, the OSR indicated, an active order dated 8/6/25 DNR (Do Not Resuscitate), SELECTIVE TREATMENT, NO ARTIFICAL MEANS OF NUTRITION INCLUDING FEEDING TUBES.During an interview on 12/22/25 at 11 a.m. with the Director of Nursing (DON), the DON stated when EMS arrived, There were two POLST Page 1 of 2 555701 555701 01/22/2026 Simi Healthcare Center 5270 East Los Angeles Avenue Simi Valley, CA 93063

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few forms-one signed by the doctor and the other not signed. The signed POLST was from 2023, and the newer POLST from 2024 reflected similar treatment selections but was missing the physician's signature. The DON stated EMS expressed confusion regarding which POLST to follow. The DON further stated that responsibility for ensuring completion of the POLST form rests with the admission nurse, the DON, and the social services team. The DON acknowledged that upon Resident 1's readmission, the updated POLST form was overlooked for physician's signature. During a review of the facility's policy and procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST), dated 01/09, the P&P indicated, Procedures: 2a Review the documents for validity. MUST be signed by the physician and the resident or the legally recognized health care decisionmaker. If the resident is a readmit to this facility, ask the resident or legally recognized health care decisionmaker if the document is still current. 555701 Page 2 of 2