Health inspection·April 12, 2024

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 3/14/24 at 11:30 a.m. with SC,the facility's High Temp Dish Machine monitoring log that was completed for the AM Reading was reviewed. The AM Reading column, dated 3/14/24 indicated Sanitizer - 180 degrees F, Rinse - 154 degrees F, and Wash - 164 degrees F, with DW 1 initial's next to the logged data. SC was unable to explain how the temperatures were recorded as such when SC said the dish machine was found to be off. The directions located on the High Temp Dish Machine indicated, Sanitizer Temp > 180 F, Rinse Temp > 160 F, Wash Temp > 150 F. SC stated that he had a supervisory role over the dish machine area. SC stated DW 1 had not reported any problems to him related to the high temperature dish machine. During a concurrent observation and interview on 3/14/24 at 11:35 a.m., SC had DW 1 run another load of dishes through the high temperature dish machine, and SC stated the wash water temperature continued to show 110 degrees F, and the final rinse temperature was 200 degrees F. During a concurrent observation and interview on 3/14/24 at 11:49 a.m., SC ran another load of dishes through the high temperature dish machine and stated the wash water reached 110 degrees F, and the rinse water temperature gauge reached 150 degrees F, and the final rinse temperature was greater than 180 degrees F. SC stated the high temperature dish machine manufacturer's guidelines were not being met for the wash and rinse cycles. During an interview on 3/14/24 at 12:13 p.m. with RD, RD stated his main responsibility was clinical nutrition services for the residents in skilled nursing facility. RD stated he had weekly, scheduled meetings with DDS/CDM and Executive Chef primarily related to menus and dining room services for residents residing in the skilled nursing facility. RD stated, there was not a structure, nor schedule in place, in which he would provide oversight over safe and sanitary conditions in the main kitchen. RD stated he had conducted a couple of mock surveys on 5/2/23 and 10/30/23, in which there were no concerns with the high temperature dish machine temperatures noted. RD stated there was not a formal schedule in place, or expectation, as to when another mock survey (kitchen audit) may be performed. During a review of the facility's High Temp Dish Machine (HTDM) temperature monitoring logs, dated 11/1/23 through 3/14/24, the Sanitizer column that should be greater than or equal to 180 degrees F was recorded less than 180 degrees F for 23 of 136 logged entries. During the same time period the Rinse column that should be 160 degrees F or greater was recorded less than 160 degrees F for 59 of 136 logged entries. During the same time period the Wash column that should be greater than or equal to 150 degrees F was recorded less than 150 degrees F for 10 of 136 logged entries. The HTDM temperature monitoring log had a location at the bottom of the log that indicated, Issues, Concerns, Unusual Incidents that was blank for the logs reviewed 11/1/23 through 3/14/24. During an interview on 3/14/23 at 1:06 p.m. with DDS/CDM and RD, DDS/CDM verified there was not effective oversight related to reviewing the HTDM temperature monitoring log in order to identify sanitation concerns in a timely manner for prompt resolution for the health and safety of residents. RD and DDS/CDM confirmed there was no routine, scheduled RD oversight/monitoring related to sanitation of the main kitchen. During a review of the facility's policy and procedure (P&P) titled, High Temp Machine Ware Washing, dated 6/21/21, the P&P indicated, Policy/Purpose: All flatware, serving dishes, and utensils are washed, rinsed, and sanitized after each use. The machine for ware washing will be checked prior to each meal period to ensure that it is functioning properly.Procedure.Temperatures should be at least: Wash - Temp 150 F, Rinse - Temp 160 F, Sanitizer - Temp 180 F . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 2 of 10 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 04/12/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's job description titled Director, Dining Services (DDS), dated 7/11/23, the DDS indicated, 3. Makes routine inspections of all work, storage and serving areas to ensure that regulations and sanitations procedures are being followed. During a review of the facility's job description titled Dietitian/Nutritional Services Manager (RDM), dated 8/2/23, the RDM indicated, 9. Monitor food service operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as, state and federal regulations. 2. During a concurrent observation and interview on 3/14/24 at 11:54 a.m., with Sous Chef (SC), SC observed a dish washer (DW 2) place another load of foodservice equipment into the wash water compartment at the 3-compartment sink. SC checked the wash water temperature, located in the first compartment, utilizing a digital thermometer and SC stated, It's 100 degrees F. DW 2 checked the concentration of the sanitizer, located in the third compartment, with a sanitizer concentration testing strip, and DW 2 stated, It's 100 [PPM -parts per million]). It's been in use a while. Should be changed. DW 2 stated the sanitizer concentration should be at 200 PPM in order to effectively sanitize. DW 2 stated the sanitizing solution located in the third compartment that tested at 100 PPM had been there since 6 a.m. During a concurrent interview and record review on 3/14/24 at 11:58 a.m. with SC, a log located near the 3-compartment sink titled Three Compartment Daily Sanitizer Log (3CSL) was reviewed. The 3CSL indicated, Chemical reading should be between 150-350 ppm. SC verified the 3CSL had not provided direction to dish washing staff to monitor the temperature of the wash water compartment to ensure it was at least 110 degrees F while in use. During a review of the manufacturer's guidelines (MGs) located on the bottle of sanitizer that facility used in the third compartment of the 3-compartment sink, the MG's 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 least 60 seconds. During a review of the facility's policy and procedure (P&P) titled, 3 Comp Sink P&P, dated 7/23/2021, the P&P indicated, Follow the 5 steps for appropriate use of the 3 compartment sink, to ensure that all items are washed and sanitized appropriately. This will ensure the safety for all people dining on our food. Procedure: While there are only three sinks, there are five essential steps you need to complete when using your three compartment sink.2) Clean items in the first sink. Wash them in detergent solution at least 110 degrees F. replace the water when the suds are gone or the water is dirty.4) Sanitize them in the third sink. Soak in sanitizer solution. Soak time and temperature should be based on manufacturer's recommendation, with a minimum soak time of 60 seconds. The chemical levels must be checked with the test strip, every time the water is changed and solution is added. Currently our chemical levels should read between 200-400 ppm.5) Air dry all items. Place items upside down so they will drain. During an interview on 3/14/24 at 12:13 p.m. with RD, RD stated his main responsibility was clinical nutrition services for the residents in skilled nursing facility. RD stated he had weekly, scheduled meetings with DDS/CDM and Executive Chef primarily related to menus and dining room services for residents residing in the skilled nursing facility. RD stated, there was not a structure, nor schedule in place, in which he would provide oversight over safe and sanitary conditions in the main kitchen. RD stated he had conducted a couple of mock surveys on 5/1/23 and 10/30/23. RD stated there was not a formal schedule in place, or expectation, as to when another mock survey (kitchen audit) may be performed. RD stated he was not responsible for providing the main kitchen with a 3-compartment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 3 of 10 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 04/12/2024 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 0801 sink monitoring log. Level of Harm - Minimal harm or potential for actual harm During a review of the RD's kitchen audits, dated 5/1/23 and 10/30/23, there was no concern noted related to the pot and pan washing area, and no documentation to indicate identifying the 3CSL was not providing direction to dish washing staff that aligned with the facility's 3 Comp Sink P & P guidance. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, 3 Comp Sink P&P, dated 7/23/2021, the P&P indicated, Follow the 5 steps for appropriate use of the 3 compartment sink, to ensure that all items are washed and sanitized appropriately. This will ensure the safety for all people dining on our food. Procedure: While there are only three sinks, there are five essential steps you need to complete when using your three compartment sink.2) Clean items in the first sink. Wash them in detergent solution at least 110 degrees F. replace the water when the suds are gone or the water is dirty.4) Sanitize them in the third sink. Soak in sanitizer solution. Soak time and temperature should be based on manufacturer's recommendation, with a minimum soak time of 60 seconds. The chemical levels must be checked with the test strip, every time the water is changed and solution is added. Currently our chemical levels should read between 200-400 ppm.5) Air dry all items. Place items upside down so they will drain. During a review of the facility's job description titled Director, Dining Services (DDS), dated 7/11/23, the DDS indicated, 3. Makes routine inspections of all work, storage and serving areas to ensure that regulations and sanitations procedures are being followed. During a review of the facility's job description titled Dietitian/Nutritional Services Manager (RDM), dated 8/2/23, the RDM indicated, 9. Monitor food service operations to ensure conformance to nutritional, safety, sanitation and quality standards, as well as, state and federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 4 of 10 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 04/12/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure the correct portion size for the regular diet orders, with regular portion sizes (i.e.; meaning not a small portion or large portion) was served following the planned menu. This facility failure had the potential to not meet the resident's nutritional needs for 20 residents who were prescribed a regular diet, with regular portions, per the facility's Resident Diet Information, dated 3/14/24, provided by the Registered Dietitian (RD). (Resident's 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20). Findings: During a concurrent observation and interview on 3/14/24 at 12:01 p.m. with RD in the trayline kitchen (trayline kitchen was the name used by the facility referring to the kitchen that plated food for residents who used meal trays), a Server (1) was observed using a 4 (four) ounce (oz.) serving spoon to plate the main entree of Shrimp and Sausage Jambalaya for the regular diet with regular portion sizes. RD observed the 4 oz. serving spoon placed in the pan of shrimp and sausage Jambalaya located in the steam table. RD asked Server 1 how much Jambalaya she was serving to the residents with a regular diet order on regular portions. Server 1 pointed to the serving spoon labeled as 4 ounces located in the shrimp and sausage jambalaya pan, and Server 1 stated Four ounces. RD showed Server1 the planned menu, as listed on each resident's individual meal tray ticket that listed 8 (eight) oz. next to Shrimp and Sausage Jambalaya for regular diet, regular portion orders. Server 1 stated then I need an 8 oz. spoon. RD stated to Server 1 to go ahead and continue to use the 4 oz. serving spoon but to serve two spoons of the Jambalaya. Server 1 repeated she needed an 8 oz spoon or scoop size, and RD 1 repeated it was okay to use the 4 oz. serving spoon but serve two 4 oz portions to equal 8 ounces. RD 1 verified with the dietary aide's that three meal delivery carts had already left the trayline kitchen for distribution of the lunch meal to residents. During a concurrent interview and record review on 3/14/24 at 1:30 p.m. with RD, a Resident Diet Information list provided by RD was reviewed that indicated there were 20 residents on a regular diet with regular portions. A review of the planned lunch menu for regular diet with regular portions indicated Shrimp and Sausage Jambalaya - 8 oz. During a review of the facility's policy and procedure (P&P) titled, Portion Control, dated 10/4/2022, the P&P indicated, Policy/Purpose: Individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. Procedure: 2. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so staff can refer to the proper portions for each diet. 3. Food should be served with ladles, scoops, spoodles, and spoons of standard sizes.a. Portions that are too small result in the individual not receiving the nutrients needed. During a review of the facility's P&P titled, Menu Planning, undated, the P&P indicated, Policy/Purpose: Nutritional needs of individuals will be provided in accorance with the established national standards.Regular and therapeutic menus will be written.in adequate amounts at each meal to satisfy recommended daily allowances.The registered dietitian (RDN -Registered Dietitian Nutritionist).will approve all menus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 5 of 10 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 04/12/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's job description titled Dietitian/Nutritional Services Manager (RDM), dated 8/2/23, the RDM indicated, 10. Monitor food control systems such as food temperatures, portion control, preparation methods, garnishment and presentation of food in order to ensure that food is prepared and presented in an acceptable manner. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 6 of 10 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 04/12/2024 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 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 sanitary conditions were maintained in the food and nutrition services when: Residents Affected - Many 1. The high temperature dish machine was not reaching proper wash, rinse and final rinse temperatures in order to effectively sanitize in accordance with the manufacturer's guidelines. 2. The three compartment sink used to wash pots and pans was not implemented in an effective manner to properly wash and sanitize the foodservice equipment. 3. The tube to dispense sanitizer was located in the hand washing sink. These failures had the potential to result in cross contamination and food borne illness in a highly susceptible resident population in which the majority of residents were on oral diets. Cross Reference F801 Findings: 1. During a concurrent observation and interview on 3/14/24 at 11:16 a.m. with dish washer (DW) 1 in the main kitchen, DW 1 was observed running breakfast dishes through the high temperature dish machine. DW 1 observed the wash temperature gauge affixed externally to the dish machine and DW 1 stated the wash water reached 110 degrees F (Fahrenheit), the rinse temperature gauge reached 130 degrees F, and the final rinse temperature gauge reached 158 degrees F. DW 1 was observed to continue to use the high temperature dish machine to wash the resident's dishes from the morning breakfast. During a concurrent observation and interview on 3/14/24 at 11:21 a.m., upon surveyor request, the Sous Chef (SC) observed the high temperature dish machine while in use. SC stated the final rinse temperature needed to reach 180 degrees F in order to have sanitized the dishes. SC observed the final rinse temperature was not reaching 180 degrees F. SC went to the side of the high temperature dish machine and stated the switch (located under a label titled Heater) was not turned on, the dish machine was off as indicated by a red light was not showing per SC. SC verified kitchen staff were almost done washing the dishes. During a concurrent interview and record review on 3/14/24 at 11:30 a.m. with SC,the facility's High Temp Dish Machine monitoring log that was completed for the AM Reading was reviewed. The AM Reading column, dated 3/14/24 indicated Sanitizer - 180 degrees F, Rinse - 154 degrees F, and Wash - 164 degrees F, with DW 1 initial's next to the logged data. SC was unable to explain how the temperatures were recorded as such when SC said the dish machine was found to be off. The directions located on the High Temp Dish Machine indicated, Sanitizer Temp > 180F, Rinse Temp > 160 F, Wash Temp > 150F. SC stated that he had a supervisory role over the dish machine area. SC stated DW 1 had not reported any problems to him related to the high temperature dish machine. During a concurrent observation and interview on 3/14/24 at 11:35 a.m., SC had DW 1 run another load of dishes through the high temperature dish machine, and SC stated the wash water temperature continued to show 110 degrees F, and the final rinse temperature was 200 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 7 of 10 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 04/12/2024 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 During a concurrent observation and interview on 3/14/24 at 11:49 a.m., SC ran another load of dishes through the high temperature dish machine and stated the wash water reached 110 degrees F, and the rinse water temperature gauge reached 150 degrees F, and the final rinse temperature was greater than 180 degrees F. SC stated the high temperature dish machine manufacturer's guidelines were not being met for the wash and rinse cycles. Residents Affected - Many During a concurrent observation and interview on 3/14/24 at 1:06 p.m. with Director of Dining Services (DDS) and the Registered Dietitian (RD), DDS stated SC informed him the high temperature dish machine was not meeting manufacturer's guidelines after surveyor identified the problem and he (DDS) then contacted an outside service to assess the high temperature dish machine. At that time, the outside service was observed in the main kitchen working on the high temperature dish machine. DDS stated the outside service informed him the dish machine was not meeting temperatures in accordance with manufacturer directions and a heating element needed to be replaced. During a review of the facility's policy and procedure (P&P) titled, High Temp Machine Ware Washing, dated 6/21/21, the P&P indicated, Policy/Purpose: All flatware, serving dishes, and utensils are washed, rinsed, and sanitized after each use. The machine for ware washing will be checked prior to each meal period to ensure that it is functioning properly.Procedure.Temperatures should be at least: Wash - Temp 150 F, Rinse - Temp 160 F, Sanitizer - Temp 180F . During a review of the manufacturer's directions located on a data plate (DP) affixed to the high temperature dish machine, the DP indicated, Final Sanitizing Rinse Minimum Temperature: 180 degrees F, Pumped Rinse Tank Minimum Temperature: 160 degrees F, Wash Tank Minimum Temperature: 150 degrees F. During a review of the FDA (Food & Drug Administration) Food Code Annex (FDAFC), dated 2022, the FDAFC indicated, The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing machine has been tested, and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. (FDA Food Code Annex 3, 4-204.113 Warewashing Machine, Data Plate Operating Specifications.) During a review of the FDAFC, dated 2022, the FDAFC indicated, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. (FDA Food Code Annex 3, 4-501.15 Warewashing Machines) 2. During an observation on 3/14/24 at 11:22 a.m. in main kitchen, a dish washer (DW) 2 was washing pots, pans, and large food storage containers at the 3 (three)-compartment sink, in which first compartment contained wash water, second compartment contained rinse water, and third compartment contained a sanitizing solution. During an observation on 3/14/24 at 11:29 a.m., in main kitchen, DW 2 removed a large food storage bin and large lid from the second compartment and placed into the third compartment (sanitizer). The large food storage bin and lid were partially immersed into the sanitizing solution, with the other half sticking up above the sanitizing solution. During a concurrent observation and interview on 3/14/24 at 11:47 a.m. with Sous Chef (SC) at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 8 of 10 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 04/12/2024 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 3-compartment sink in the main kitchen, DW 2 was observed removing the large food storage bin and lid from the 3-compartment sink and placed on a rack to air dry. SC stated, It was not okay. SC verified the foodservice equipment was not completely sanitized as half of the equipment was not immersed into the sanitizer solution. SC verified once the foodservice equipment was placed on the rack to air dry the equipment would be available for use. Residents Affected - Many During a review of the manufacturer's guidelines (MGs) located on the bottle of sanitizer that facility used in the third compartment of the 3-compartment sink, the MG's 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 least 60 seconds. Articles too large for immersing must be visibly wetted by rinsing, spraying, or swabbing. During a concurrent observation and interview on 3/14/24 at 11:54 a.m., with SC, SC observed DW 2 place another load of foodservice equipment into the wash water compartment at the 3-compartment sink. SC checked the wash water temperature, located in the first compartment, utilizing a digital thermometer and SC stated, It's 100 degrees F. DW 2 checked the concentration of the sanitizer, located in the third compartment, with a sanitizer concentration testing strip, and DW 2 stated, It's 100 [PPM -parts per million]). It's been in use a while. Should be changed. SC and DW 2 stated the sanitizer concentration should be at 200 PPM in order to effectively sanitize. DW 2 stated the sanitizing solution located in the third compartment that tested at 100 PPM had been there since 6 a.m. During a concurrent interview and record review on 3/14/24 at 11:58 a.m. with SC, a log located near the 3-compartment sink titled Three Compartment Daily Sanitizer Log (3CSL) was reviewed. The 3CSL indicated, Chemical reading should be between 150-350 ppm. SC stated the facility had not required staff to check the wash water temperature at the 3-compartment sink to ensure it was an appropriate temperature while in use. During a review of the facility's policy and procedure (P&P) titled, 3 Comp Sink P&P, dated 7/23/2021, the P&P indicated, Follow the 5 steps for appropriate use of the 3 compartment sink, to ensure that all items are washed and sanitized appropriately. This will ensure the safety for all people dining on our food. Procedure: While there are only three sinks, there are five essential steps you need to complete when using your three compartment sink.2) Clean items in the first sink. Wash them in detergent solution at least 110 degrees F. replace the water when the suds are gone or the water is dirty.4) Sanitize them in the third sink. Soak in sanitizer solution. Soak time and temperature should be based on manufacturer's recommendation, with a minimum soak time of 60 seconds. The chemical levels must be checked with the test strip, every time the water is changed and solution is added. Currently our chemical levels should read between 200-400 ppm.5) Air dry all items. Place items upside down so they will drain. 3. During a concurrent observation and interview on 3/29/24 at 11:05 a.m. with lead diet aide (LDA) in the trayline kitchen (staff refer to that kitchen as trayline kitchen and/or medical [skilled nursing facility] kitchen), a long tube was curled up and laying on the sink bed of a designated hand washing sink. LDA stated the tube was used to dispense sanitizer solution and should not have been located in the hand washing sink. LDA pointed to the food production sink and stated the tube should be over in that area as it was used to dispense sanitizer for food contact surfaces. During a concurrent observation and interview on 3/29/24 at 11:38 a.m. with Executive Chef (EC) in the medical/trayline kitchen, EC observed the outlet portion of the long tube that was used to dispense sanitizer solution was located in the hand washing sink. EC verified the tube should not be in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 9 of 10 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 04/12/2024 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 the hand washing sink as it was an infection control concern. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Hand Washing, undated, the P&P indicated, Procedure: Use only hand sinks designated for that purpose. Do not wash hands in sinks in the production area. Dry hands with single use towels or a mechanical hot dryer.Turn off faucets using a paper towel in order to prevent recontamination of clean hands. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 10 of 10