Health inspection·October 20, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to update the medical records with current wishes for life sustaining treatment (POLST-Physician Order for Life Sustaining Treatment) for one of three sampled residents (Resident 8). This failure had the potential to prevent facility staff and emergency personnel from providing life sustaining treatment to Resident 8 in case of emergency. Findings: During a review of Patient 8's medical record, the POLST (POLST-Physician Order for Life Sustaining Treatment), dated [DATE] indicated, Attempt Resuscitation/CPR (life sustaining treatments in an emergency). The Face Sheet and Physician Order Sheet effective through [DATE] indicated, DNR (DNR-Do Not Resuscitate). During a concurrent interview and record review on [DATE] at 11:50 a.m., Patient 8 reviewed the POLST dated [DATE] and confirmed the signature, date, and Attempt Resuscitation/CPR on the POLST are correct. Resident 8 stated, Yes, in an emergency I want CPR. During a concurrent record review and interview with licensed nurse 1 (LN1) on [DATE], at 12:02 p.m., Resident 8's medical record was reviewed. The POLST dated [DATE] indicated Attempt Resuscitation/CPR. The Face Sheet, and Physician Order Sheet effective through [DATE] indicated DNR (Do Not Resuscitate). When asked if the Face Sheet and Physician Order Sheet for DNR were updated to reflect Resident 8's wishes for life sustaining treatment on the POLST, LN1 stated No. LN1 indicated, this was the only POLST the facility had for Resident 8. During a review of the facility policy and procedure titled Advance Directives dated [DATE], the policy and procedure indicated in part, [Facility Name] has defined advance directives as preferences regarding treatment options which will include, but not be limited to: Polst - a physicians order for life sustaining treatment .Changes or revocations of a directive will be submitted to [Facility Name] in writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 2 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an accurate system for monitoring parameters of nutritional status for one of 2 sampled residents (Resident 16), when: Residents Affected - Few 1. An inaccurate nursing weekly assessment failed to identify a significant weight loss which resulted in a missed referral to the Registered Dietitian (RD). 2. An inaccurate weight goal was documented on the interdisciplinary team (IDT) nutrition care plan that had not been assessed by the RD or involved the decision making of the participant or responsible party (RP). 3. The facility lacked monitoring of a nutrition intervention, such as a high protein shake, when delivered with the meal trays. 4. The IDT nutrition care plan was not updated and revised to reflect changes the RD made to the intervention for weekly weights. As a result, there was potential for the resident's nutritional needs to go unmet. Findings: 1. During a concurrent interview and record review on 10/19/22 at 01:50 p.m., with RD, Resident 16's admission Nutrition Assessment (ANA), dated 8/23/21, was reviewed. RD stated, Resident 16 weighed 93 pounds (lbs) on 8/23/21 and had already lost 9 lbs since admission on [DATE]. RD stated, he assessed Resident's 16's daily calorie needs to promote weight gain as the goal. During a review of Resident 16's Weight Vitals the following weights were noted: 8/10/21 - 102 lbs 8/18/21 -93 lbs 8/23/21 - 96 lbs 6/14/22 - 108 lbs 7/14/22 - 109 lbs 8/15/22 - 110 lbs 9/15/22 - 110 lbs 10/16/22 - 104 lbs During a concurrent interview and record review on 10/19/22 at 02:10 p.m., with RD, RD stated, changes in a resident's weight, either weight loss or weight gain, is brought to his attention via referral after a nurse identifies the weight change via the nursing weekly assessments conducted for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 3 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents. Resident 16's Weekly Summary (WS), dated 10/19/22 was reviewed. The WS indicated, weight was documented as 104 lbs and a check mark was listed for Stable next to the category of Weight Gain/Loss. The same WS listed the following directions, If gain/loss of 3 lbs in one week or 5 lbs in one month, was MD and RD notified?, with a check mark next to N/A [not applicable. RD stated, the weekly summary was not accurate, and he should have received a referral because the resident had more than a 5 lb weight loss in one month. RD stated, Resident 16 weighed 110 lbs on 9/15/22, and weighed 104 lbs on 10/16/22 which was a 5.45% significant unplanned weight loss. RD verified the facility missed providing a referral to the RD due to inaccurate weekly nursing assessment. During a concurrent interview and record review on 10/19/22 at 03:23 p.m., with director of nursing (DON), DON reviewed Resident 16's Weekly Summary (WS), dated 10/19/22. DON verified the inaccuracy when a nurse documented 104 lbs as stable under weight section. DON stated, Resident 16 should have been noted for weight loss and the nurse should have referred to the RD. During a review of the facility's policy and procedure (P&P) titled, Clinical Documentation, dated 4/5/2017, the P&P indicated, 7. All entries shall be complete, concise, descriptive and accurate. During a review of the facility's policy and procedure (P&P) titled, Weight Variance, dated 3/31/2017, the P & P indicated, c. A licensed nurse will verify any weight variance of 5 pounds or more in 30 days or 3 pounds in one week, by immediate reweigh, and will report to RD if verified . 2. During a concurrent interview and record review on 10/19/22 at 01:50 p.m., with RD, Resident 16's admission Nutrition Assessment (ANA), dated 8/23/21, was reviewed. The ANA indicated Resident 16 weighed 93 pounds (lbs) on 8/23/21 and had already lost 9 lbs since admission on [DATE]. RD stated he assessed Resident's 16's daily calorie needs to promote weight gain as the goal. During a review of Resident 16's Weight Vitals the following weights were noted: 8/10/21 - 102 lbs 8/18/21 -93 lbs 8/23/21 - 96 lbs 6/14/22 - 108 lbs 7/14/22 - 109 lbs 8/15/22 - 110 lbs 9/15/22 - 110 lbs 10/16/22 - 104 lbs During a concurrent interview and record review on 10/19/22 at 02:30 p.m., with RD, Resident 16's Interdisciplinary Nutrition Care Plan (IDT NCP), initiated on 8/16/22 and current through 11/15/22 was reviewed. The IDT NCP indicated a goal of, Resident will maintain current wt. [weight] of 104 lbs +- 5 lbs for the next 3 months. IBW (ideal body weight) 108-132 lbs . RD stated, I never assessed a goal weight. RD stated, he noticed that as a routine the MDS Coordinator puts +- 5 lbs for most (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 4 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents on the IDT nutrition care plans, without a resident being individually assessed as a goal weight, and without involvement of the resident and/or RP. RD stated, I do not document anything on the IDT nutrition care plans, the MDS Coordinator does. RD verified that documenting a weight goal to include a further weight loss of five pounds (from 104 - 99 lbs), after already having a significant unplanned weight loss, was not acceptable nor within geriatric nutrition standards of practice, as weight loss leads to loss of lean body mass which should be avoided, when possible. RD verified the IDT Nutrition Care Plan was not accurate for Resident 16's documented goal weight. During a review of the facility's policy and procedure (P&P) titled, Weight Variance, dated 3/31/2017, the P&P indicated, Policy/Purpose: .to ensure all residents maintain proper nutrition and body weight. Any unplanned significant weight loss/gain is investigated and every reasonable effort to reverse the weight variance is made .Procedure: .d. The RD will compute the percentage of weight variance. Any variance 2% weight loss in a week, 5% in 30 days, 7.5% in a 90 day period and 10% in 180 day period will trigger the following: 2. The Registered Dietitian will: a. Assess each resident with a significant weight, makes appropriate recommendations to physicians and update resident care plan . During a review of the facility's policy and procedure (P&P) titled, Care Planning/Interdisciplinary Team, dated 3/28/2017, the P&P indicated, The Medical Center Care Planning/Interdisciplinary Team will develop a comprehensive person centered care plan for each Medical Center Resident. Procedure; 2. The care plan will be developed by the Medical Center Planning/Interdisciplinary Team which will include, but not necessarily be limited to: .e. Dietitian .3. To the extent practicable, the resident, the resident's family or the resident's legal representative will participate in the development of the care plan . 3. During a concurrent interview and record review on 10/19/22 at 01:50 p.m., with RD, Resident 16's admission Nutrition Assessment (ANA), dated 8/23/21, was reviewed. RD stated, Resident 16 weighed 93 pounds (lbs) on 8/23/21 and had already lost 9 lbs since admission on [DATE]. RD stated he assessed Resident's 16's daily calorie needs to promote weight gain as the goal. RD stated, he added a nutrition intervention of in-house protein shakes, three times a day, monitor weight, and labs. RD stated each in house protein shake provided 310 calories and 28 grams of protein. RD was asked how he monitored intake of the protein shake, and RD stated, he asks nursing if the resident has been drinking the protein shakes. RD acknowledged nursing would not be able to recall the quantity of shake consumed on any given day and facility had not been documenting consumption of protein shake consumed when it was delivered on meal trays. RD verified lack of documenting quantity consumed of a nutrition intervention, such as the protein shakes, would impede the RDs ability to assess calorie and protein intake to compare to a resident's assessed daily needs, resulting in a less accurate nutrition assessment. RD acknowledged lack of documentation of quantity consumed of a nutrition intervention also was not effective for monitoring effectiveness and identifying when an alternative nutrition approach may be warranted. During a concurrent interview and record review on 10/19/22 at 03:42 p.m., with director of nursing (DON) in the presence of the RD, the DON verified the facility had not been documenting quantity consumed of the protein shakes for Resident 16. The DON reviewed the Vitals Report that included documentation for amount of food eaten from breakfast, lunch and dinner completed by certified nursing assistants (CNAs), and there was no documentation specific to the consumption of the protein shakes for Resident 16. DON verified the facility had not been documenting quantity of consumption of nutrition interventions that are delivered with the meal trays, that could include high protein house shakes, Ensure, Magic Cup, Beneprotein, etc. (those are nutrition supplements/interventions that could be prescribed to increase calorie and protein intake) to monitor for effectiveness. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 5 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acknowledged the facility did have a method to document quantity consumed of nutrition interventions that are delivered during the medication pass, documented on the MAR, but needed to also do it for the nutrition interventions that were delivered on the meal trays. The RD and DON acknowledged separating intake of nutrition interventions from the food provided during routine mealtimes, would allow a method for monitoring the effectiveness or when it may become necessary to re-evaluate, and to improve the accuracy of nutrition assessments. During a review of the facility's policy and procedure (P&P) titled, Dietary Assessment, dated 3/31/2017, the P&P indicated, 2. A dietary assessment will be conducted and such information will include at least the resident's: .e. Nutritional intake . During a review of the facility's policy and procedure (P&P) titled, Meal Percentages, dated 3/31/2017, the P&P indicated, Staff will document the percentage of food consumed by each resident at every meal to ensure that every resident receives adequate nourishment to maintain the highest quality of life possible . 4. During a concurrent interview and record review on 10/19/22 at 01:50 p.m., with RD, Resident 16's admission Nutrition Assessment (ANA), dated 8/23/21, was reviewed. RD stated, Resident 16 weighed 93 pounds (lbs) on 8/23/21 and had already lost 9 lbs since admission on [DATE]. During a review of Resident 16's Interdisciplinary Nutrition Care Plan (IDT NCP), dated 8/27/21 and current through 11/15/22, the IDT NCP indicated, Monitor/record weight weekly. Notify MD and family of significant weight change. During a concurrent interview and record review on 10/20/22 at 10:05 p.m., with certified nursing assistant (CNA 1), CNA 1 provided the binder that contained the residents on Weekly Weights was reviewed, dated from April 2022 through October 11, 2022. CNA 1 verified the last entry for Resident 16 was in April 2022. CNA 1 stated the RD removed Resident 16 from weekly weights to monthly weights starting in May 2022. During a telephone interview on 10/20/22, at 10:15 a.m., with RD, RD stated, he changed the nutrition care plan to weigh Resident 16 monthly, instead of weekly, beginning in May 2022. The RD stated the facility's system was for the MDS Coordinator to review the RD notes to see what changes were made for the MDS Coordinator to update the IDT NCP. RD stated he could have communicated with the MDS Coordinator, as well, but did not. During an interview on 10/20/22, at 10:33 a.m., with MDS Coordinator, MDS Coordinator stated, she should have looked at the RD's notes for any change to update and revise the IDT NCP and did not. During a review of the facility's policy and procedure (P&P) titled, Care Planning/Interdisciplinary Team, dated 3/28/2017, the P&P indicated, The Medical Center Care Planning/Interdisciplinary Team will develop a comprehensive person centered care plan for each Medical Center Resident. Procedure; 2. The care plan will be developed by the Medical Center Planning/Interdisciplinary Team which will include, but not necessarily be limited to: a. Attending physician, b. Director of Nursing, c. Licensed nurse who has responsibility for the resident, d. Nursing assistants responsible for resident care, e. Dietitian . During a review of the facility's policy and procedure (P&P) titled, Dietitian, dated 3/31/2017, the P&P indicated, 2. The dietitian will (but not necessarily be limited to): .d. Participate in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 6 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0692 interdisciplinary care planning . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Clinical Documentation, dated 4/5/2017, the P&P indicated, 7. All entries shall be complete, concise, descriptive and accurate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 7 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 follow it's policy and procedures (P&P) (set of rules for employees to follow in an organization) for disposition (process for destroying unused medications) of expired and controlled medications (medications that are potential for abuse), and to reconcile (record keeping) accounting for controlled medications brought from home to the facility by family members for one unsampled resident (Resident 229) when the following was observed on [DATE], during a facility tour: 1. Eight packets of 4 vials each, 0.9% sodium chloride inhalation (nebulazer solution), expiration date 1/17, located at second floor Medication Room. 2. A small biohazard sharps container with narcotic medication as reported by the licensed staffs, located at first floor west station medication cart narcotic drawer. 3. A bottle of Hydrocodone (opiod to treat pain) with 12 tablets and the narcotic count sheet wrapped around the bottle located at first floor west station medication cart narcotic drawer. 4. A plastic bag filled with Fentanyl patches (opiod for pain management) located at first floor west station medication cart narcotic drawer. This failure had the potential to place resident's safety at risk if procedures for accurate acquiring, receiving, dispensing, and administering of all drugs are not followed to meet the needs of each resident. Findings: 1.During an interview with the Minimum Data Set Coordinator (MDSC - nurse responsible for each resident's assessment as required by the Centers for Medicare and Medicaid Services in a nursing facility), on [DATE], at 10:05 a.m., MDSC confirmed and verbalized medications were expired, and should have been checked for expiration date per manufacturer's recommendation and removed from the cabinet. During a review of the facility's P&P, titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated, [DATE], the P&P indicated, Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. 2. During an interview with the Licensed Vocational Nurse (LN 2), on [DATE], at 10:52 a.m., LN 2 verbalized, medications that were dropped, refused by a resident, including narcotics were placed inside the biohazard sharps container, and required two nurses signed off on the narcotic count sheet. Once the container is filled up, the container will be given to the Director of Nursing (DON) and will be placed in a bucket of solution for destruction. LN 2 observed the surveyor opened the sharps container by hand. LN 2 further verbalized, anyone can have access and use the narcotic medication in the sharps container. During an interview with the Licensed Vocational Nurse (LN 1), on [DATE], at 12:15 a.m., LN 1 verbalized and verified that the sharps container inside the narcotic drawer were used for any dropped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 8 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 medication, medication refused by the residents, both narcotics and non-narcotics are placed inside the biohazard sharps container, after two nurses signed off the narcotic count sheet. LN 1 further verbalized, that is how she does it. During an interview with the DON, on [DATE] 9:20 a.m., the DON agreed and verbalized, problem in the current system of disposing the narcotic in the sharps container done by the nurses on the floor. DON further verbalized, the narcotic medication should be placed inside the sharps container, instead the narcotics should have been turned in to her for disposal with the pharmacist. 3. During an interview with MDSC, on [DATE], at 12:18 p.m., MDSC verbalized, the bottle of medication was brought by the resident's (Resident 229) family so Resident 229 can have it while waiting for the medications to be delivered by the pharmacy. MDSC further verbalized, the medication does not have a narcotic count sheet, so the nurses created one, but did not place it on the narcotic log for reconciliation. During an interview with the DON, on [DATE] 9:30 a.m., the DON verbalized, narcotic medications that were brought from home to the facility by the resident's family, must be counted, and recorded. The DON further verbalized, the narcotic count sheet was not included in the narcotic logbook for reconciliation. 4. During an interview with LN1, on [DATE], at 12:23 p.m., LN 1 verbalized, narcotic count sheets are turned in to the medical records once patches are used. The used patches are collected and given to the DON for destruction. During an interview with the DON, on [DATE], at 9:17 a.m., the DON verbalized, Fentanyl patches must be given to the DON once administered and removed from the resident, once two nurses sign off on the narcotic count sheet. The narcotic count sheet will be given, not to the medical records, but to the DON for reconciliation and destruction of the patches with the pharmacist. The DON further verbalized, and verified, the narcotic count sheet with the used patches was not given to her for reconciliation and destruction. During a review of the facility's P&P, titled, Inventory of Controlled Substances, dated [DATE], the P&P indicated, A Facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile: 5.1 Current and discontinued inventory of controlled substances to the log used in Facility's controlled medication inventory system. 5.2 Current inventory to the controlled medication declining inventory record and to the resident's MAR (Medication Administration Record); and 5.3 Unused controlled substances held in storage awaiting destruction with the declining inventory record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 9 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one of 12 sampled residents (Resident 23) had been assessed for the use of antipsychotic (medicine for mental disorders) while having a diagnosis of dementia (a condition of the brain affecting ability to remember, think or make decisions with doing everyday activities), as outlined in the manufacturer's black box warning. Residents Affected - Few This failure resulted in Resident 23, taking this medication and placed Resident 23, at increased risk of death as outlined by the black box warning and making this as inappropriate drug for Resident 23. Findings: During a review of an untitled document, dated, 10/20/22, the untitled document, indicated, the interdisciplinary team (IDT) (team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together), reviewed Resident 23's plan of care. The untitled document further indicated, Resident 23 had been on Seroquel (type of medicine for mental disorder) while having a diagnosis of dementia. During a review of Resident 23, Doctor's Progress Notes, dated 5/31/22, the Doctor's Progress Notes, indicated, Resident 23 was on Seroquel for a diagnosis of delusional behavior while having a diagnosis of Dementia. During a review of the document, titled, Omnicare Drug Information - Quetiapine Fumarate, dated 10/20/22, the Omnicare Drug Information - Quetiapine Fumarate, indicated, This medication is not approved for the treatment of dementia-related behavior problems. During a review of the document on 10/20/22, at 4:23 p.m., with the DON, the DON googled the package inserts (a document included in the package of a medication that provides information about the drug and its use) for Seroquel manufactured by Astra [NAME], dated, 6/16, the package inserts for Seroquel indicated, Warning: Increased mortality in elderly patients with dementia-related psychosis; and suicidal thoughts and behaviors. Elderly patients with dementia-related psychosis are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis. During an interview with the DON, on 10/20/22, at 4:23 p.m., the DON verbalized and acknowledged, the facility had been giving this medication for the treatment of Resident 23's diagnosis of delusional behavior with the diagnosis of dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 10 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services when: Residents Affected - Some 1. The dishwasher was unable to accurately record dish machine wash water and sanitizing (final rinse) temperatures. The dishwasher was not competent to know when to report a problem to ensure properly washed and sanitized dishes were used for residents. 2. A pot washer was not competent on the correct concentration of sanitizer for the 3-compartment sink to ensure the pots and pans were effectively sanitized. 3. A cook was not competent on thermometer calibration to ensure temperatures obtained were accurate to promote food safety for the residents. These failures placed residents at risk of cross contamination and acquiring foodborne illness. 1. During a concurrent observation and interview on 10/17/22, at 10:00 a.m., with Dish Washer (DW 4), in the main kitchen, DW 4 was observed running dishes through the dish machine. In the presence of the Sous Chef (SC), who translated for DW 4, DW 4 stated, he was responsible for completing the dish machine temperature monitoring log. DW 4 stated the wash water temperature gauge that was attached to the machine should be between 160-165 degrees Fahrenheit (F). During a concurrent interview and record review, on 10/17/22, at 10:05 a.m., with SC and DW 4, the ADC Forty Four Low Temp Dish Machine (temp monitoring log), dated 10/1/2022 through AM (morning) reading on 10/17/2022, was reviewed. The column under Temp [temperature] indicated ten entries were documented as 80 (degrees F). DW 4 verified it was his initials next to the documented entries but was unable to explain where those numbers came from or what they meant, despite stating the wash water temperature should be between 160-165 degrees F. During a concurrent observation and interview on 10/17/22 at 10:08 a.m., with SC and DW 4, DW 4 pointed to an external gauge that indicated Rinse that he said he used to complete the column titled Sanitizer on the temp monitoring log, which had entries that ranged from 162 degrees F through the highest temperature documented was 180 degrees F. The 180 degrees F was documented two times from 10/1/2022 - 10/17/2022. SC stated, DW 4 pointed to the wrong temperature gauge to use for the Sanitizer column. SC pointed to another temperature gauge that was located toward the back right hand side of the dish machine and was labeled as Final Rinse .180 degrees F. SC stated, a final rinse temperature of 180 degrees F would indicate the dishes were sanitized. SC verified it was the final rinse temperature gauge results that should be recorded on the dish machine temperature monitoring log under the Sanitizer column. SC acknowledged DW 4 was not competent in accurately monitoring the temperature gauges for the wash and final rinse (sanitizing) temperatures for the dish machine. During a joint observation on 10/17/22, at 10:10 a.m., in the main kitchen, with SC, the external wash water temperature gauge on the dish machine was observed to reach 150 degrees F (that matched the guidance affixed to the dish machine wash water temperature gauge), and the Final Rinse temperature gauge toward the back of the machine reached 190 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 11 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 10/17/22 at 10:43 a.m , with the Chef (1), the ADC Forty Four Low Temp Dish Machine, dated 10/1/2022 - 10/17/2022, was reviewed. Chef 1 stated, the incorrect log form was being used as it was for a low temperature dish machine and the facility had a high temperature dish machine. Chef 1 acknowledged guidance on the expected temperatures for the wash and final rinse cycle were not readily available to DW 4 since the wrong dish machine temperature monitoring log was being used. Chef 1 verified DW 4 was not competent on his assigned duties of dish washer. During a concurrent interview and record review on 10/17/22 at 10:45 a.m., with Chef 1, Chef 1 reviewed the dish machine log used from 9/1/2022 through 10/1/2022 titled, CMA High Temp Dish Machine that included directions on the log of, Sanitizer Temp greater than or equal to 180 F, Rinse Temp greater than or equal to 160 F, Wash Temp greater than or equal to 150 F. Chef 1 verified the Sanitizer column should be used for the Final Rinse temperature gauge and if it does not reach 180 degrees F, that meant the dishes were not sanitized. A review of the log indicated 80 was documented under the Sanitizer twenty-eight out of thirty-one entries on the log for the AM (morning shift) temperature. Chef 1 verified DW 4 was not competent on his assigned duty as dish washer. In addition, Chef 1 verified there was inadequate monitoring of the logs by himself or the Certified Dietary Manager (CDM), to identify the problem and rectify it immediately to ensure the health and safety of the residents. The CDM was not on site to interview. During a review of the facility's policy and procedure (P&P) titled, Dish Machine Temperature Log, dated 2021, the P&P indicated, Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: The director of food and nutrition services will post a log near the dish machine for the staff to document temperature .1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. 3. Staff will be trained to report any problems with the dish machine to the director of food and nutrition services as soon as they occur. 4. The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. 2. During a concurrent observation and interview on 10/17/22, at 10:15 a.m., with a dish washer (DW 5) in the presence of the Sous Chef (SC), who translated for DW 5, in the main kitchen, the three- compartment sink was observed filled with wash water, rinse water and sanitizer. DW 5 used a chemistry strip and immersed the strip into the sanitizing solution, located in the third compartment of the 3-compartment sink. DW 5 compared the color to the color-coded graph on the chemistry strip vial, and DW 5 stated, It's 100 [PPM; parts per million]. SC observed the chem strip and verified it was 100 PPM. DW 5 stated he last used the three -compartment sink to wash pots and pans at 9:20 a.m. that morning. DW 5 stated, 100 PPM was okay, and said the sanitizer concentration should be between 100 - 200 PPM. DW 5 stated, he has worked as a pot washer at the facility for three years. During a review of the Three Compartment Daily Sanitizer Log (3CDSL), dated 10/1/2022 through the AM (morning) shift of 10/17/2022, DW 5 documented the sanitizer was 100 PPM five times that month for the AM shift. According to the directions on the Three Compartment Daily Sanitizer Log, the log indicated, Chemical reading should be between 150-350 ppm. However, according to the manufacturer's guidelines (MGs) located on the bottle of sanitizer that was used in the third compartment sink, the MGs indicated, To sanitize food processing equipment, utensils, and other food contact articles .in a three - compartment sink: .4. Sanitize by immersing articles with a use-solution 200-400 ppm .for at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 12 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some least 60 seconds . SC verified the manufacturer's guidelines for the sanitizer should have been followed and the sanitizer concentration should be 200-400 ppm to effectively sanitize. During an interview on 10/17/22, at 10:43 a.m., with Chef 1, Chef 1 stated, he verified the sanitizer was documented as 100 PPM on the 3CDSL, and it is low. In addition, Chef 1 verified there was inadequate monitoring of the logs by himself or the Certified Dietary Manager (CDM), to identify the problem and rectify it immediately to ensure the health and safety of the residents. The CDM, whose job description was titled Director, Dining Services per Chef 1, was not on site to interview. During a review of the facility's job description for Potwasher/Dishwasher, the job description indicated, 1. Wash all china, dishes, silverware, pots, pans and utensils with appropriate chemicals and equipment. 2. Sanitizes dishes and utensils in manner dictated by state regulations . During a review of the facility's policy and procedure (P&P) titled, Cleaning Dishes - Manual Dishwashing, the P & P indicated, Policy: Dishes and cookware will be cleaned and sanitized after each meal. Procedure: .Sink 3: Sanitize. Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following the manufacturer's guidelines) . During a review of the facility's job description (JD) titled, Director, Dining Services, dated 7/18/2022, the JD indicated, 3. Makes routine inspections of all work, storage and serving areas to ensure that regulations and sanitations procedures are being followed . 3. During a concurrent observation and interview on 10/18/22, at 09:26 AM., with a [NAME] (1), in the kitchen, cook 1 was observed to have a digital thermometer. [NAME] 1 stated she calibrates the digital thermometer once a week. [NAME] 1 stated, she waits until the digital thermometer reads 0 degrees Fahrenheit (F) to determine when the thermometer has been calibrated. [NAME] 1 proceeded to demonstrate how she calibrates the thermometer. [NAME] 1 immersed the digital thermometer in ice water and [NAME] 1 stated she waits for ten seconds. [NAME] 1 stated, it shows 39.9 degrees F, and stated that was fine and meant it was calibrated. During an interview on 10/18/22, at 09:43 AM, with Registered Dietitian (RD), RD stated, he expected staff to calibrate the thermometers using the ice method. RD was asked what temperature he would expect to determine the thermometer was calibrated, and RD stated, Would expect zero degrees F for thermometer calibration and will check with thermometer specifications since they are all different and the cook has been trained on that. RD stated, he would get a copy of the in-service provided to the cook because the Chef would do that. During a concurrent interview and record review on 10/18/22 at 10:20 AM., with Team Lead Supervisor (TLS), TLS provided documentation of monthly in-services given on thermometer calibration. TLS stated, 39.9 degrees F means the thermometer was not calibrated as it should have reached 32 degrees F to show it was calibrated. During a review of the in-service titled Instructions for calibrating pocket Thermometer, dated 10/1/22, the in-service indicated, Remove thermometer from sheath and immerse stem a minimum of two inches into a 50/50 ice and water slush bath when positioned at the end, use the hexagon opening as a wrench to calibrate. Holding the dial with one hand and the sheath with the other, adjust calibration nut until indicator reads 32 F at sea level The in-service signature page had not contained [NAME] 1's signature. In addition, the in-service directions had not pertained to the type of thermometer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 13 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0802 in use by [NAME] 1, which was a digital thermometer. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Calibrating the thermometer, undated, the P&P indicated, For all thermometers, follow the manufacturer's directions for calibration. There are two ways to calibrate a bimetallic thermometer: the ice point method and the boiling point method. Thermometers should be calibrated at least monthly. The P & P guidance had not reflected specific guidance to staff related to the digital thermometer that was used by [NAME] 1. Residents Affected - Some During a review of the facility's staff job description titled Dietitian/Nutritional Services Manager, dated 8/22/21, the job description included, Essential Job Duties: .9. Monitor food service operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as state and federal regulations .,10. Monitor food control systems such as food temperatures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 14 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure a cook followed the puree recipe for a puree egg omelet as a method to ensure nutritive value. Residents Affected - Few As a result, the resident was provided a puree egg omelet with less nutritive value than planned. Findings: During a concurrent observation and interview on 10/18/22, at 11:21 a.m., with [NAME] (1), in the kitchen, [NAME] 1 was observed to prepare pureed egg omelet. [NAME] 1 stated, she had one pureed egg omelet to make as a food preference for lunch that day for a resident. [NAME] 1 stated she placed three cooked eggs into the food processor. [NAME] 1 was observed to add one cup of milk and one cup of water and thickener to the food processor. [NAME] 1 was asked how much thickener she used, and [NAME] 1 stated, We don't really measure the thickener. [NAME] 1 stated she goes by overall puree texture consistency versus paying attention to how much thickener was used. [NAME] 1 was shown how much thickener was observed in the glass measuring cup that was added to the food processor and [NAME] 1 verified the amount used was a quarter cup of thickener. [NAME] 1 was asked if she had a puree egg omelet recipe available for guidance, and [NAME] 1 stated, When I need it. [NAME] 1 was asked where the puree egg omelet recipe was located, and [NAME] 1 stated, With [name of team lead supervisor]. During a concurrent interview and record review on 10/18/22 at 11:26 a.m., with team lead supervisor (TLS), TLS stated [NAME] 1, Was supposed to follow the recipe and measure the thickener because too much thickener can displace the nutrients. TLS provided the recipe that should have been followed titled Scrambled Egg that indicated, Puree: Place prepared portions needed into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 1 TBSP [tablespoon] thickener and ¼ [quarter]cup water or milk; mix well with a wire whip. Add the slurry to the eggs; process until smooth . During an observation on 10/18/22, at 11:50 p.m., in the kitchen, Resident 22's menu was observed on the countertop for tray line (where the meals are assembled), which had a handwritten note on the menu puree omelet. During a review of the facility's policy and procedure (P&P) titled, Standardized Recipes, dated 2013, the P&P indicated, Policy: Standardized recipes are used when preparing menu items. Procedure: 1. Standardized recipes (in appropriate portion sizes) for each set of cycle menus are maintained in the facility .3. Cooks/chefs are expected to use and follow the recipes provided . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 15 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to ensure the Registered Dietitian provided care within the scope of practice guidelines of the California Business and Professions Code 2586 (a)(1) when the facility approved order writing privileges to the RD related to writing orders for nutritional supplements and therapeutic diets. As a result, the RD was performing services outside of RD scope of practice per State law. Findings: During a concurrent interview and record review on 10/19/22 at 01:40 p.m., with Registered Dietitian (RD), Resident 16's admission Nutrition Assessment (ANA), dated 8/23/21 was reviewed. The ANA indicated Resident 16 had a significant unplanned weight loss since admission. RD stated, he added an intervention of protein shakes three times a day. During an interview on 10/19/22 at 01:45 p.m., with RD, RD stated, the doctors practicing at the facility granted him order writing privileges RD stated, he was allowed to write orders to modify therapeutic diets and write orders for nutrition supplements without first obtaining an order from the physician. RD verified that he was informed he did not have to obtain orders for the above things, and that he could write the therapeutic diet orders or supplement orders on the physician order section, without a verbal or telephone order from the MD. RD verified this practice could apply to any resident; it was not specific to Resident 16. RD stated, the order writing privileges were granted soon after he began working at the facility, approximately one year ago. During an interview on 10/19/22 at 03:42 p.m., with RD and Director of Nursing (DON), the DON verified the facility had a policy and procedure that the facility doctor's approved allowing the RD to write direct orders to modify therapeutic diet orders and for nutrition supplements. The RD stated, he was concerned about the policy and procedure to be granted order writing privileges, initially. During a review of the facility's policy and procedure (P&P) titled, Nutrition Related Ordering Guidelines, undated, the P&P indicated, Policy: As part of the medical interdisciplinary team the Registered Dietitian (RD) may write and implement nutrition orders/recommendations that affect the nutritional care of our residents. Procedure: 1. The RD may write orders for nutritional supplements (House supplements, protein shakes, Magic Cup, TwoCal HN, Beneprotein etc.- These are all supplements to increase calories and protein which could impact a resident's weight). 2. The RD may write orders for screening/evaluation for speech therapy and occupational therapy when related to chewing/swallowing problems or feeding skill., 3. The RD may write orders for changes in therapeutic diets. 4. The RD may write orders to downgrade the texture of diet. The RD will refer to speech therapy for a follow-up evaluation . During a review of the facility's policy and procedure (P&P) titled, Dietitian, dated 3/31/2017, the P&P indicated, 2. The dietitian will (but not necessarily be limited to): b. Develop and write therapeutic orders as delegated by the attending physician . The above policy and procedures allowed the RD to work out of RD scope of practice according to the practice guidelines of the California Business and Professions Code (BPC) 2586 (a)(1), and BPC 2586 (b). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 16 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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: 1. Expired, leftover lentil soup that had not been cooled down safely was available for use in the walk-in refrigerator, and 2. The ice machine dispenser located in a kitchenette was not clean. As a result, residents were placed at risk for developing a food borne illness. Findings: 1. During a concurrent observation and interview on 10/17/22, at 09:35 a.m., with Sous Chef (SC), in the main kitchen's walk-in refrigerator, was a large pan of prepared potato salad. The SC stated, he cooked thirty pounds of potatoes that morning. SC stated he cooked the potatoes to 165 degrees Fahrenheit (F) and put them in the reach-in freezer for one hour in which they were then 39 degrees F. SC stated he does not write down the cool down process on a cool down log. SC verified the potato salad would be served for lunch that day to include the residents living in the skilled nursing facility. During a concurrent observation and interview on 10/17/22, at 10:26 a.m., with team leader supervisor (TLS), in the skilled nursing facility's (SNF) kitchen's walk-in refrigerator, was a large pan of lentil soup dated 10/9/22. TLS stated, he did not know if the main kitchen prepared the lentil soup or by the staff in the SNF kitchen. TLS stated the lentil soup should not be there because the facility does not store leftovers. TLS verified lentil soup is a TCS (time/temperature control for food safety) and/or a PHF (potentially hazardous food capable of supporting microbial growth) food item and would have needed to be cooled down safely. TLS verified the facility does not have a cool down log to demonstrate it was cooled down safely. TLS stated, he would ask the Chef if the facility had a policy and procedure on cool down. TLS stated the facility had shelf -life guidelines that he was not able to locate at the time, and TLS stated in general food is not stored more than three days. During an interview on 10/17/22, at 10:43 a.m., with the Chef (Chef 1), Chef 1 stated, they have not been using a cool down log for the potatoes for the potato salad, and he was unsure who cooked the lentil soup. Chef 1 verified potatoes and lentil soup are both PHF foods and he does not know about a cool down log but will ask the Certified Dietary Manager (CDM) who was currently out of town. Chef 1 stated the facility did not have a policy and procedure (P & P) on cool down for TCS and/or PHF foods. During an interview on 10/18/22, at 9:16 a.m., with Chef 1, Chef 1 confirmed the facility cooks TCS/PHF foods that do go through the temperature danger zone (pathogens grow within this temperature range), to include items such as potatoes, pasta, and lentils that would need to be cooled down for food safety. Chef 1 confirmed the facility lacked a cool down log to monitor the cool down process for food safety and lacked a P & P on cool down. During a review of the facility's policy and procedure (P&P) titled, Use of Leftovers, dated 2021, the P&P indicated, Policy: Excess leftovers should be avoided. Leftovers will be properly handled and used or discarded as appropriate. Leftover foods will not be used for pureed diets. Procedure: .3. Leftovers must be cooled to 70 degrees F within 2 hours and then to 41 degrees F within another 4 hours. 4. Leftovers that have not been properly stored will be discarded. (When in doubt, throw it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 17 of 18 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 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 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 out.) 5. Food that is leftover will be handled as noted above and may be used as follows. A. Leftovers can be used within 7 days (the day of preparation is counted as day 1 according to the 2017 Federal Food Code) and if reheated to 165 degrees F for a minimum of 15 seconds for hot foods . During a review of the facility's policy and procedure (P&P) titled, Food Safety - Director of Food and Nutrition Services' Responsibilities, dated 2021, the P & P indicated, Policy: The director of food and nutrition services will be responsible for providing safe foods to all individuals. Procedure: The director of food and nutrition services should assure all the following: 1. HACCP [Hazard Analysis Critical Control Point] procedures will be followed ., 3. All refrigerated and frozen foods will be stored and handled properly . 2. During an interview on 10/17/22, at 10:43 a.m., with Chef (1), Chef 1 stated, the ice-machines are cleaned by an outside service company. Chef 1 provided an invoice from the outside service company, dated 9/29/22, that indicated Description; Perform monthly Preventive Maintenance on customer owned equipment per agreement. Always sanitize ice equipment during each PM .performed preventative maintenance on med [medical center/skilled nursing facility] second floor . During a concurrent observation and interview on 10/17/22, at 12:02 p.m., with the facility's designated infection preventionist (IP), in the kitchenette on the 2nd floor next to the resident's dining room, the ice machine dispenser was observed to have white discoloration and small black spots on the inside and outside of the ice-machine dispenser. The IP was asked if it was acceptable to serve ice to residents from the ice-machine, and the IP stated, Probably not, but I'll have to check. The IP stated, the small white spots were probably calcium build-up, and verified the small black spots indicated the dispenser was not in a clean condition. The IP showed a form located in a folder on the wall titled, Kitchen Cleaning Checklist. The IP stated, the housekeeping staff complete the tasks on the kitchen cleaning checklist. Next to number 6. on the checklist indicated Ice Machine with a hand -written note in that column that indicated, Juice Machine General Clean. During an interview on 10/17/22, at 12:05 p.m., with housekeeper (HK 1), in a hallway on the 2nd floor, HK 1 stated, housekeeping does not clean any parts of the ice machine that was in the kitchenette. During a review of the ice-machine's manufacturer's guidelines (MG's) provided by the facility, the MG's included, If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. If required, an extremely dirty ice machine may be taken apart for cleaning and sanitizing . During a review of the Federal and Drug Administration (FDA) Food Code 2017 Annex, Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. (4-602.11) During a review of the FDA Food Code 2017, the FDA Food Code indicated, that ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. (4-602.11 Equipment Food-Contact Surfaces and Utensils) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 18 of 18