Health inspection·January 12, 2024

F 0640 been completed and submitted in a timely manner and it was not . Level of Harm - Minimal harm or potential for actual harm During a review of the, Centers for Medicare and Medicaid Services (CMS - a federal agency that provides effective health care coverage and promote quality care for people with Medicare) Resident Assessment Instrument (RAI - a tool which helps the nursing home staff gather information on the residents' strengths and needs so it can be addressed through a care plan) Version 3.0 Manual, Chapter 2: Assessments for the RAI, dated 10/2023, indicated in part, For unplanned discharges, the facility should complete the OBRA (Omnibus Budget Reconciliation Act of 1987 also known as the Nursing Home Reform Act - sets federal standards of care for nursing homes) discharge assessment to the best of its abilities. An unplanned discharge includes, for example: Acute care transfer of the resident to a hospital or emergency department in order to stabilize a condition . Resident unexpectedly deciding to go home or to another setting (e.g., due to the resident deciding to complete treatment in an alternate setting. The RAI manual further indicated, . 09. Discharge Assessment - Return Not Anticipated (A0310F = 10) . Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days . Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days) . Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Develop a person-centered interdisciplinary team nutrition care plan (IDTNCP - detailed plans of care created by representatives from several medical disciplines or specialties) for one of 16 sampled residents (Resident 37) to include the resident's goals and desired outcomes. In addition, the IDTNCP lacked clear and specific measurable objectives and physician input, related to a planned weight gain for Resident 37. This failure resulted in unclear measurable weight gain goal and impedes the IDT from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure care needs would not go unrecognized and unmet. 2. Develop a care plan for one of 16 sampled residents (Resident 35) receiving blood thinners. This failure had the potential to result in medication adverse consequences to not be monitored. Findings: 1. During a concurrent interview and record review on 1/10/24 at 11 a.m. with Registered Dietitian (RD), Resident 37's admission Nutrition Assessment (NA), dated 12/4/23, was reviewed. The NA indicated, Resident 37's admit weight was 98 pounds (lbs) and his usual body weight (UBW) was 108 lbs. RD stated she assessed Resident 37's nutritional needs at 30-35 calories per kg (kilogram) to promote weight gain because his BMI was low and because he had already lost weight from a previous admission to the facility. RD stated she wanted Resident 37 to gain weight. The NA also contained a check mark next to maintain weight. RD stated in her mind when she marked a goal of maintain weight it meant that weight loss was not the goal, and the goal was at a minimum to maintain weight with the desire for weight gain. RD stated she did not specifically document what the weight goal was but in my mind I would want him to re-gain weight to his UBW (usual body weight) of 108 lbs. RD verified the weight goal was not clearly documented in the NA. During a concurrent interview and record review on 1/10/24 at 11:30 a.m., with RD, RD stated she had not discussed that she assessed Resident 37's daily nutritional needs to promote weight gain with the resident or what his weight gain goal would be to ensure resident centered care. During a review of Resident 37's Weight Variance Progress Notes (WV), dated 1/10/24, the WV indicated, Resident 37 currently weighed 112 lbs, and the recommendation/plan was Continue POC (plan of care) diet, fluids, nutritional supplements, monitoring po intake, wts [weights], and all other nutritional parameters. Dc [discontinue] from weekly weight monitoring. During a concurrent interview and record review on 1/10/24 at 11:35 a.m. with RD, Resident 37's IDT Nutrition Care Plan (IDTNCP), initiated by RD on 12/06/23, was reviewed. The IDTNCP included, Problem: . 12/20/23 gain of 3 lbs x 1 wk r/t [related to] po [by mouth] intake w/ [with] augmentation of nutritional supplement, 12/29/2023: + desirable 4 lbs or 3.7% weight gain x 1 week. + Good meal intakes and SF [sugar free] house shake daily, 1/10/24 Sig [significant] wt [weight] gain at 1 mon [month] r/t good po intake w/augmentation of nutritional supplement, Revision on: 1/10/24 .Goal: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .Maintain weight +/-5% q [every] month x 3 months .Target Date: 03/03/2024 . RD stated, the goal indicated, Maintain weight +/-5% q month x 3 months. RD stated, the goal was not for weight loss, so the -5% of weight as part of the goal would not be applicable and was not accurate. RD verified the goal in her mind was for the resident to gain weight to UBW of 108 lbs. RD verified without a measurable goal the IDT would not know when the rate of weight gain or amount of weight gain might be of concern. RD verified without a specific measurable goal weight listed, the IDT would not be able to effectively monitor the POC, nor know when to revise when appropriate. During a concurrent interview and record review on 1/10/24 at 11:38 a.m., with Director of Nursing (DON), Resident 37's IDT nutrition care plan (IDTNCP), initiated by RD on 12/06/23, was reviewed. DON stated, the documented goal was, Maintain weight +/-5% q month x 3 months. DON verified the goal was not for the resident to lose weight, therefore the care plan goal was not accurate when it included -5% as being part of the goal. DON stated the goal is for weight maintenance or +5% weight gain. DON verified the IDT nutrition care plan had not contained clear, measurable goals when DON was unable to answer what the maintenance weight was, and was not aware RD assessment was for a planned weight gain, and was unable to state how much weight gain was planned, based on the IDT nutrition care plan, since the measurable goal was not clear. In addition, DON confirmed the expectation was for the IDT care plans to be developed with the participation of the physician, and with the resident's goals for outcomes which would include a planned weight gain. 2. During a review of Resident 35's History and Physical (H&P), dated 11/9/23, the H&P indicated Resident 35 was admitted on [DATE] with a history of atrial fibrillation (when the heart beats irregularly which can produce blood clots leading to stroke or heart related death) and taking Eliquis (a blood thinning medication that controls blood clots). During a concurrent observation and interview on 1/9/24 at 2:57 p.m. with Resident 35, in the room, Resident 35 was observed sitting up in wheelchair and stated, I have heart disease and take Eliquis. During a concurrent interview and record review on 1/11/23 at 3:35 p.m. with a licensed nurse (LN 3), Resident 35's clinical record was reviewed. LN 3 verified Resident 35 was taking Eliquis but unable to find documentation of a nursing care plan for monitoring. During a concurrent interview and record review on 1/12/23 at 8:27 a.m. with the DON, Resident 35's clinical record was reviewed. Resident 35's, Order Summary Report (OSR), dated 11/8/23, indicated in part, . Eliquis tablet, give10 milligrams (mg), by mouth, twice a day for seven days ending 11/15/23 .and Eliquis tablet, give 5 mg, twice a day . Resident 35's, Medication Administration Record (MAR), dated 12/1/23 - 1/11/24, was also reviewed and indicated the same Eliquis order. The DON stated the Eliquis order was current. When asked if a care plan was developed in conjuction with Resident 35 taking Eliquis, DON was unable to find a documented care plan and acknowledged one should have been developed as it was the facility's policy. During a review of the facility's policy and procedure (P&P) titled,Care Planning And Care Plans, dated April 2013, the P&P indicated, Purpose: To ensure that this facility is in compliance with the regulations by ensuring that the resident is provided with appropriate and individualized care; To provide a communication tool to the Interdisciplinary Team who is responsible for giving care on an individualized [NAME] .Guidelines: 1. The Comprehensive Care Plan is developed and revised by the IDT, with the participation of the resident and/or resident representative ., 2 .it includes measurable objectives and timetables to meet the resident's . needs that are identified in the comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm assessment ., 3. Patient care plans are to be initiated on admission of a patient and based on the physician's orders and assessments made of the patient ., 4. The care plans are updated as the resident conditions change and as revision is needed . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain and provide a prescribed, routine antihypertensive medication (a medication used to lower blood pressure) ordered for one of three sampled residents (Resident 40). This failure had the potential to result in uncontrolled blood pressure levels and subsequent complications for Resident 40. Findings: During a medication pass observation on 1/10/24 at 9:18 a.m. with a licensed nurse (LN 4), Resident 40's Losartan Potassium (a medication to treat high blood pressure) scheduled to be administered for 9 a.m. was not available in the medication cart. During a concurrent interview and record review on 1/10/24 at 11:11 a.m. with LN 4, LN 4 stated, This resident (referring to Resident 40) just transitioned from short-term to long-term care ( short stay to long stay in the facility). The pharmacy does not auto refill ( automatic dispensing) medications for short term residents, only for long term. LN 4 verbalized the medication was reordered on paper and showed the facility form titled, Medication Reorder Sheet, dated 1/8/24, was faxed to the pharmacy. LN 4 could not confirm if the faxed reorder form was received by the Pharmacy (1/10/24 the medication is not available in the facility to administered). LN 4 confirmed all resident medications prescribed to be given in the facility should be available at all times. During a review of Resident 40's, Electronic Health Record (EHR), the Medical Diagnosis section dated 12/14/23 indicated, Resident 40 was a [AGE] year-old female with admitting diagnoses including, chronic obstructive pulmonary disease (COPD - a group of diseases that causes airflow blockage and breathing-related problems), chronic atrial fibrillation (quivering of the heart), and essential hypertension (HTN - high blood pressure). Further review of Resident 40's EHR, under Medication Review Report, the report indicated, a medication order for Losartan Potassium oral tablet 100 mg (milligrams), give one tablet by mouth one time a day for HTN. During a review of the facility's policy and procedures (P&P) titled, Medication Ordering and Receiving From Pharmacy Provider, dated 9/2010, the P&P indicated in part, Ordering and Receiving Non-Controlled Medications . Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. The P&P indicated further, Procedure . 1.c: If not utilizing cycle fill or anniversary fill system, all medications shall be reordered in advance by writing the medication name and prescription number, or applying the peel-off bar coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacy. During a review of the facility's P&P titled, Medication Administration General Guidelines, dated 5/16, the P&P indicated in part, Procedures - Medication Administration .14) Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review of the facility's P&P titled,Medication Med Pass and Treatment Times, dated 7/23, the P&P indicated in part, Procedure .2) Medication Pass times will be as follows: QD (Daily) 9 AM . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the facility's Consultant Pharmacist (CP) identified and reported irregularities during the medication regimen review (MRR) when nonpharmacological interventions (NPI) were not implemented for the behaviors exhibited for depression and psychosis for one of 16 sampled residents (Resident 34) This failure had the potential to result in Resident 34 receiving unnecessary medications. Findings: During a review of Resident 34's, Medication Administration Record (MAR), dated 1/1-1/31/24, the MAR indicated the following medication orders: Seroquel Oral Tablet (Quetiapine Fumarate), give 37.5 mg (milligram) by mouth one time a day for psychosis, manifested by aggressive behavior at 4 p.m. (start date: 12/9/23), Seroquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth one time a day for psychosis, manifested by aggressive behavior at 9 am (start date: 1/4/24), and Fluoxetine HCl (Prozac) capsule 20 mg, give one capsule by mouth one time a day for depression with anxiety manifested by demonstrating restlessness as evidenced by picking at own skin (start date: 1/4/24). No documentation of the NPI monitoring for psychotic behaviors and picking of skin was noted or located in Resident 34's MAR. During a concurrent interview and record review on 01/12/24 9:26 a.m., with the director of nursing (DON) and nurse supervisor (NS), confirmed NPI's were not documented as implemented in the MAR for Resident 34 and should have been. During a concurrent interview and record review, on 1/12/24, at 9:51 a.m., with the facility's consultant pharmacist (CP) and Manager of Clinical Operations (MCO), in the presence of the DON and NS, Resident 34's psychotropic medication profile was reviewed. The CP confirmed that implementation of NPI's were not reviewed with Resident 34's monthly medication review and acknowledged failing to identify that NPI's were not being implemented while Resident 34 was on psychotropic medication. Review of facility's policy and procedure (P&P) titled, Medication Monitoring 8.1 Medication Regimen Review and Reporting, dated 01/23, the P&P indicated: Policy: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative. Procedures: 2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professional involved in the resident's care. During a review of the facility's, policy and procedures (P&P), titled, Psychotherapeutic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medication Use, dated 5/2013, the P&P indicated in part, .1) The facility will exhaust alternative methods necessary to manage a resident's behavior as much as possible; The initial approach to management of behavioral symptoms in older adults should focus on environmental modifications, behavioral interventions, psychotherapy or other nonpharmacologic interventions .4) A Monthly Summary on the Use of Psychotherapeutic Medications is done to determine the frequency that a behavior was manifested for the past month . During a review of facility's, P&P, titled, Use of Antipsychotic Medications, dated 5/2013, the P&P indicated in part, .2) This facility will exhaust alternative methods necessary to manage a resident's dementia-related behavior as much as possible. The initial approach to management of behavioral symptoms in older adults is focused on environmental modifications, behavioral interventions, psychotherapy, or other non-pharmacological means . 4) Interventions are implemented, monitored and revised as appropriate 5) A monthly summary of behavior manifestation is done and then becomes the basis for recommendation for dose change or maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure its medication error rate during medication pass observation was less than five percent (5%). The facility had a cumulative medication error rate of 10.34% when three errors out of 29 opportunities for errors were observed between two licensed nurses (LN 2 and LN 4) who administered medication to two sampled residents (Residents 25 & 40) and one unsampled resident (Resident 547). The observed medication administration errors were: Residents Affected - Few 1. LN 4 administered one capsule of Urox (a medication that supports bladder control) by mouth to Resident 25 instead of the prescribed order of two capsules. 2. LN 2 failed to administer the full dose of Clearlax (a laxative to treat occasional constipation) mixed in apple juice to Resident 547 when half of the mixture was thrown away. 3. LN 4 administered one puff of Tiotropium Bromide Monnohydrate (Spiriva - an inhaled medication that relaxes and opens the air passages of the lungs) to Resident 40 instead of the prescribed two puffs. These failures had the potential to compromise the health and safety of these residents. Findings: 1. During a medication pass observation on 1/10/24 at 8:30 a.m., with LN 4, LN 4 was observed administering one capsule of Urox 840 mg (milligram) by mouth to Resident 25. During a concurrent interview and record review, on 1/10/24, at 11:35 a.m., with LN 4, Resident 25's, Medication Review Report (MRR), dated 1/10/24, was reviewed. The MRR indicated the medication order, Urox (Lindera) 840 mg give two capsules by mouth in AM one time a day for OAB (overactive bladder) (start date of 9/2/23). LN 4 confirmed giving only one capsule to Resident 25 instead of two and acknowledged not following the order. 2. During a medication pass observation on 1/10/24 at 8:58 a.m. with LN 2, LN 2 was observed mixing Clearlax 17 gm (gram) with four oz. (ounces) of apple juice in a five oz. cup to administer to Resident 547. Resident 547 was observed to have drank only half of the mixture and the remainder thrown away by LN 2. During a concurrent interview and record review on 1/10/24 at 12 p.m., with LN 2, Resident 547's, Medication Administration Record (MAR), dated 1/1-1/31/24, was reviewed. Resident 547's MAR indicated the medication order, Miralax (different brand name for Polyethylene Glycol, same as Clearlax) Powder 17 gm by mouth in the morning for constipation .Dissolve in 4 oz. of water/juice, hold for loose stools (start date: 11/28/23). LN 2 confirmed that Resident 547 took about 50% of the mixture and did not document it in the chart. LN 2 acknowledged that she should have documented that the resident did not receive the full dose. 3. During a medication pass observation on 1/10/24 at 9:18 a.m. with LN 4, LN 4 was observed administering Tiotropium Bromide inhaler to Resident 40. The resident only received one puff of the inhaled medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 1/10/24 at 11:11 a.m. with LN 4, Resident 40's, MRR, dated 1/10/24, was reviewed. The MRR indicated the medication order, Spiriva HandiHaler Inhalation capsule 18 mcg (microgram) (Tiotropium .) two puff inhale orally one time a day for COPD (chronic obstructive pulmonary disease - a group of diseases that causes airflow blockage and breathing-related problems) .contents of one cap (18 mcg) daily inhaled with two puffs. LN 4 confirmed that Resident 40 only received one puff of the inhaled medication and acknowledged that the medication order was not followed. During a review of the facility's policy and procedures (P&P) Medication Administration, dated 5/16, the P&P indicated in part, Procedures - Medication Administration .1) Medications are administered in accordance with written orders of the prescriber .5) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR and action is taken appropriately . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure expired medications and medical supplies were discarded and not readily available for staff use. This failure had the potential to result in unsafe medication administration or ineffective therapy provided to the residents. Findings: During a concurrent observation and interview on 1/9/24 at 11:09 a.m. in the facility's medication storage room with a licensed nurse (LN 2), the following expired medications were found: six Nicotine Transdermal System patches (expired 8/23), one bottle Slow Magnesium Chloride with Calcium tablets (expired 11/23), one bottle of Calcium Citrate plus Vitamin D3 tablets (expired 11/23), and one refrigerated E-Kit (expired 10/23). LN 2 verified the expired medications found and acknowledged they should have been removed from storage and discarded. During a concurrent observation and interview on 1/9/24 at 11:34 a.m. with LN 2, the facility's treatment cart located in nurse station 2 was inspected. The following expired items were found in the cart: two boxes of Povidone Iodine wipes (expired 10/23 & 12/23), one tube of Coloplast Woun'Dres (expired 6/23), one bottle of Curad Iodine packing strip (expired 3/23), one tube of Santyl ointment (expired 2/23), one tube of Medihoney gel (expired 1/23), one tube of Skintegrity (expired 11/23), one tube of Silvasorb gel (expired 3/23), six Silvercel non-adherent dressings (expired 10/22 & 5/23), one Calcium alginate dressing (opened & expired 10/23), one Vaseline gauze strip (opened & expired 10/23), one Aquacel AG advantage dressing (expired 10/23), one Puracol plus dressing (expired 8/23), and one Enluxtra wound dressing (expired 11/19). LN 2 verified the expired medical supplies found and acknowledged they should have been removed from storage and discarded. During a concurrent observation and interview on 1/9/24 at 12:20 p.m. with LN 2, the facility's emergency crash cart was inspected. The following expired items were found: one box face Aoxing disposable masks (expired 4/22), one general IM E-kit (expired 09/30/23), two IV administration sets (expired 5/22), two Zyno Medical IV tubings (expired 8/23 & 9/23). LN 2 verified the expired medical supplies/medications found and acknowledged they should have been removed from storage and discarded. During a review of facility's, policy and procedures (P&P) titled, Central Supplies, dated 7/2023, the P&P indicated in part, Procedures 1) Do an inventory of supplies every two weeks, 2) Ensure that there is adequate quantity and quality of supplies . 4) Observe the FIFO (first-in, first out) system to ensure that no supplies on hand are outdated and expired; supplies expiring within the month are discarded/disposed appropriately . During a review of facility's P&P, titled, Medication Storage 4.1 Storage of Medication, dated 11/17, the P&P indicated in part, Policy .Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . The P&P indicated further, Procedures .14) Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe food handling when puree chicken, a TCS food (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria), was not accurately cooled down. As a result, the residents who were scheduled to be served the planned alternate entrée of puree chicken, in lieu of the main entrée of puree fish, were placed at an increased risk for developing a foodborne illness. Findings: During a concurrent observation and interview on 1/09/24 at 11:15 a.m. with Dietary Manager (DM), in the walk-in refrigerator in the kitchen, a small steam table pan of puree chicken was covered and dated 1/9/24. DM stated the puree chicken was the planned alternate for that night's dinner for the resident's on a puree diet who disliked the main entrée of puree fish. During an interview on 01/09/24 at 11:16 a.m. with Cook, [NAME] stated at 6:30 a.m. that morning he cooked chicken to an internal temperature of 165 degrees F (Fahrenheit). [NAME] stated he then pureed the chicken and placed the puree chicken in a holding pan that was on ice to cool down. [NAME] stated two hours later he checked the temperature of the puree chicken and it was 69 degrees F at 9:30 a.m. [NAME] was asked if there was a cooling log and cook pointed to a log posted on the wall in the kitchen titled, Cooling/Chilling Temperature Log. There were no documented entries on the cooling log for 1/9/24. [NAME] stated he had not yet documented any cool down temperatures for the puree chicken on the log. [NAME] was asked if there were any further steps he needed to do for the puree chicken. [NAME] stated he was done until dinner time when he would then re-heat the puree chicken to 165 degrees F to place into the steam table for dinner meal service. During a concurrent observation and interview on 1/09/24 at 11:20 a.m. with DM, DM removed the pan of puree chicken from the walk-in refrigerator and placed it on a counter in the kitchen. DM inserted a digital thermometer in the middle of the puree chicken, and DM stated, It's 59 degrees F. DM verified the thermometer obtained from the cook was calibrated that morning. DM pointed to the Thermometer Calibration Log posted on the wall that was completed that morning by the cook. During a concurrent observation and interview on 01/09/24 at 11:34 a.m. with Cook, in the presence of DM, [NAME] stated he cooked the chicken to 165 degrees F this morning. He pureed the chicken and placed the pan of puree chicken on ice and checked the temperature two hours later and it was 69 degrees F. [NAME] then stated after the 2 hour temperature check of 69 degrees F, he checked the temperature of the puree chicken again three hours later around 11:30 a.m and it was 39 degrees F. The pan of puree chicken was currently located on the counter, and DM stated the temperature was just checked and it was 59 degrees F. [NAME] was asked if he was able to explain how the temperature reached 39 degrees F at 11:30 a.m., when it was removed from the refrigerator and it was only 59 degrees F currently. [NAME] did not have an answer, and [NAME] stated, Anyway we are going to throw it out. A copy of the Cooling/Chilling Temperature Log was requested. During a review of the facility's Cooling/Chilling Temperature Log (CL) that was provided, dated 01/09/24, the CL indicated, Puree, 6:00 [am] 165 degrees F, 8:00 am 69 degrees F, 9:30 am 39 degrees F, initialed as completed by the cook. That was the only logged entry for 1/9/24 on the CL. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/09/24, at 02:46 p.m., with DM, DM stated cook should have documented the cool down process from the start on the cool down log to ensure effective monitoring for accurate and safe cool down of TCS food. DM acknowledged that cook's interview that the puree chicken reached 39 degrees F was not accurate, as the temperature was obtained at 11:34 a.m., upon surveyor request and it was 59 degrees F taken out of the refrigerator. Residents Affected - Few During a review of the facility's policy and procedure (P&P) category titled, HACCP [Hazard Analysis Critical Control Points is a systematic preventive approach to food safety] Chill Method (HACCP), dated 2017, the P&P indicated, HACCP Chill Method: (Time/Temperature Control Foods for Safety) must be cooled from: 135 degrees F to 70 degrees F within two hours and then from 70 degrees F to 41 degrees F or lower in the next four hours . During a review of the FDA Food Code Annex 2022 (Annex), the Annex indicated, Time/Temperature Control for Safety Food . Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone . too long. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 observation, interview, and record review, the facility failed to ensure documentation of non-pharmacological interventions (NPI - any intervention intended to improve the health or the well-being of individuals that do not involve the use of drugs or medicine) for the use of psychotropic medications (medications used for mood and behavior modification) in one of three sampled residents (Resident 34) was in place. Resident 34 was placed on Prozac (medication to treat depression) and Seroquel (medication to regulate mood, behaviors and thoughts) with no documented NPIs. This failure had the potential to result in incomplete data used as basis for possible continued or discontinued use of psychotropic medication usage on Resident 34 and other residents. Findings: During a concurrent observation and interview on 1/11/24 at 8:30 a.m. with certified nursing assistant (CNA 1), in the facility dining room, Resident 34 was observed eating breakfast. CNA 1 reported Resident 34 eats very well and independently, sometimes able to answer simple questions but other times not able to and usually ate meals in the dining room. CNA 1 verbalized observing Resident 34 exhibiting behaviors such as waving hands or acting like trying to hit someone and other times does not respond to conversations and seemed like not there. During an interview, on 1/11/24 at 8:21 a.m. with licensed nurse (LN 1), LN 1 stated a consent had to be obtained from the resident or responsible party (RP - family member/significant other) prior to starting the resident on psychotropic medication. A new consent is obtained when there an increase in the medication dose. LN 1 added that medication adverse effects to the resident where checked and if needed, staff would try NPIs. When asked what NPI's were implemented, LN 1 stated it was all about the approach to the residents, making them feel they are part of their care. When asked if these NPI's were documented in Resident 34's chart, LN 1 stated they were not. During a review of Resident 34's, Electronic Health Record (EHR), the EHR indicated in part, Resident 34 was admitted to the facility on [DATE], with admitting diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities) with behavioral disturbance, psychosis (a condition of the mind that results in difficulties determining what is real and what is not real), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 34's, Minimum Data Set (MDS - a federally mandated health status screening and assessment tool used for all residents of long-term care health facilities) Summary, with assessment reference date (ARD) of 11/3/23, indicated in part, Section E: Mood and Behavior Patterns . no hallucination, no delusion, no behaviors exhibited. During a review of Resident 34's, Care Plans (CP), dated 11/10/23, a CP focusing on Resident 34's, Antidepressant use, indicated interventions including, Monitor medication adverse effects . Use of protective sleeves to protect against skin picking. Another CP focusing on Resident 34's, Antipsychotic medication use indicated interventions including, Monitor/document medication adverse effects and occurrence of target behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Californian 2225 DE LA Vina Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 34's, Medication Administration Record (MAR), dated 1/1-1/31/24, the MAR indicated the following medication orders: Seroquel Oral Tablet (Quetiapine Fumarate), give 37.5 mg (milligram) by mouth one time a day for psychosis, manifested by aggressive behavior at 4 p.m. (start date: 12/9/23), Seroquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth one time a day for psychosis, manifested by aggressive behavior at 9 am (start date: 1/4/24), and Fluoxetine HCl (Prozac) capsule 20 mg, give one capsule by mouth one time a day for depression with anxiety manifested by demonstrating restlessness as evidenced by picking at own skin (start date: 1/4/24). The MAR failed to indicate NPI monitoring for psychotic behaviors and picking of skin with Resident 34's use of these medications. Further review of the Resident 34's EHR, no NPI documentation could be located . During an concurrent interview and record review, on 1/12/24, at 9:51 a.m., with the Director of Nursing (DON) and Nurse Supervisor (NS), the DON and NS confirmed NPI's were not implemented and documented for Resident 34 and both acknowledged the NPI's should have been implemented and documented. During a review of the facility's, policy and procedures (P&P), titled, Psychotherapeutic Medication Use, dated 5/2013, the P&P indicated in part, . 1) The facility will exhaust alternative methods necessary to manage a resident's behavior as much as possible; The initial approach to management of behavioral symptoms in older adults should focus on environmental modifications, behavioral interventions, psychotherapy or other nonpharmacologic interventions . 4) A Monthly Summary on the Use of Psychotherapeutic Medications is done to determine the frequency that a behavior was manifested for the past month During a review of facility's, P&P, titled, Use of Antipsychotic Medications, dated 5/2013, the P&P indicated in part, . 2) This facility will exhaust alternative methods necessary to manage a resident's dementia-related behavior as much as possible. The initial approach to management of behavioral symptoms in older adults is focused on environmental modifications, behavioral interventions, psychotherapy, or other non-pharmacological means . 4) Interventions are implemented, monitored and revised as appropriate . 5) A monthly summary of behavior manifestation is done and then becomes the basis for recommendation for dose change or maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055684 If continuation sheet Page 16 of 16