Health inspection·March 23, 2023

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the, Physician's Order, dated 3/9, the Physician's Order indicated Resident 21 was to receive Sulfamethoxazole-trimethoprim 800/160 mg, (define as antibiotic) one tablet orally every 12 hours for seven days for the right heel wound. During an interview on 3/22/23, at 9:35 a.m., with the Minimum Data Set Coordinator (MDSC 1 - an individual responsible to assess and plan care of a resident the MDS), the MDSC 1 acknowledged Resident 21 had a right heel wound infection which required antibiotic therapy. The MDSC confirmed Resident 21's representative was very involved in Resident 21's care. The MDSC also confirmed there was no documentation in the medical record to indicate Resident 21's representative was notified of the wound infection and antibiotic treatment. Event ID: Facility ID: 555236 If continuation sheet Page 2 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview and record review, the facility failed to ensure a baseline care plan was developed for one of two sampled residents (Resident 628) who had an automatic implantable cardioverter defibrillator (AICD - a small, electronic device that is implanted into the chest to monitor abnormal heart rhythm). This failure had the potential to not meet the resident's safety needs should the device malfunction. Findings: During an interview with Resident 628, on 3/20/23, at 12:20 p.m., the resident verbalized he underwent placement of cardiac stents (a small mesh tube used to hold open narrowed arteries) and AICD in December 2022. During a review of Resident 628's hospital records, an Operative Report, dated 12/30/22, indicated Resident 628 underwent a procedure with, successful completion of a dual-chamber AICD via left femoral (artery on the groin) approach. During a concurrent interview and record review, with a licensed nurse (RN 1), on 3/22/23 at 10:57 a.m., Resident 628's clinical records were reviewed. RN 1 verified through Resident 628's operative report, that the resident had an AICD device implanted. When reviewing Resident 628's care plan focusing on cardiovascular issues, there was no documentation of the baseline assessment, goals, and care interventions pertaining to the resident's AICD device. RN 1 acknowledged a baseline care plan for Resident 628 with an AICD device should have been developed. During a review of the facility's, policies and procedures (P&P), titled, Documentation of the Implementation of the Plan of Care Policy 8620-13, dated 1/23, the P&P indicated, Policy .Interdisciplinary members' responsibilities include, but are not limited to: 1) Development of a baseline care plan that is based on the initial assessment of each resident by nursing staff and or interdisciplinary team member/s .a) Be developed within 48 hours of a resident's admission, b) Include the minimum healthcare information necessary to properly care for a resident .including but not limited to .physician orders, c) Upon completion of the baseline care plan .written summary .includes but is not limited to: the initial goals of the resident, a summary of the resident's medication and dietary instructions, any services and treatments to be administered by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 3 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 43), had a comprehensive care plan (plan to care for resident), that addressed Resident 43's weight loss. Residents Affected - Few This failure resulted in Resident 43 not having interventions to prevent weight loss when Resident 43 lost 8.8 pounds (lbs.) in 6 months and had the potential for Resident 43 to have an overall decline in health status. Findings: During a review of the facility's policy and procedure (P&P) titled, Significant Unintentional Weight Change, dated 08/21, the P&P indicated, The following guidelines are used to evaluate unintentional significant weight change: 1 week - equal or greater than 2.5 % weight change; 1 month - equal or greater than 5% weight change; 3 months - equal or greater than 7.5 % weight change; 6 months - equal or greater than 10 % weight change. a). A member of the Clinical Nutrition Staff will complete a full nutrition assessment following the Nutrition Care Process, addressing, and identifying the weight change. 1. Interventions to address significant, unintentional weight change will be implemented. During a review of the facility's P&P titled, Documentation of the Implementation of the Plan of Care Policy, dated 04/13, the P&P indicated, II. Development and implementation of a comprehensive, individualized plan of care that is based on the assessments of the person .B. All appropriate services providing assessments, approaches, and goals for care of the person will be documented by appropriate discipline. During a review of Resident 43's Nutrition Services Note, dated 3/9, the Nutrition Services Note indicated Resident 43 received hemodialysis (a treatment to clean the wastes and water from the blood), had an edema (swelling), and prior history of weight changes. Resident 43 had an 8.8 lbs., (10 %) significant weight loss in 6 months. During a concurrent interview and record review on 3/21/23 at 8:35 a.m., with the Minimum Data Set Coordinator (MDSC 1 - an individual responsible to assess and plan care of a resident using a standardized tool used in a Medicare or Medicaid certified facility), Resident 43's Nutritional Care plan, dated 1/21, was reviewed. The MDSC 1 confirmed Resident 43's Nutritional Care Plan was last updated on 1/21/23, when Resident 43 had a weight change of 5% in a month. The MDSC 1 further acknowledged the care plan was not updated to reflect Resident 43's significant weight loss and should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 4 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Many 1. the planned menu was followed when incorrect portion sizes were given of the mashed potatoes for the 17 residents on the regular diet (Resident 52, 2, 51, 49, 41, 24, 48, 10, 62, 127, 130, 132, 133, 135, 621, 622, 625, 58 and 16 residents on the carbohydrate controlled diets (Resident 36, 27, 25, 22, 53, 8, 56, 66, 23, 122, 125, 126, 128, 131, 623, 628); and of the zucchini for the 15 residents on the heart healthy or low sodium diet (Resident 33, 14, 46, 25, 38, 42, 7, 20, 6, 121, 123, 124, 129, 134, 627; 2. the menus reflected the needs of the resident's when they had a lack of variety for five residents on a puree diet (Resident 3, 19, 5, 26, 421); 3. the menus were updated periodically. These deficient practices had the potential to affect the resident population because of decreased food variety, food repetition, and could lead to lack of interest in eating and could result in weight loss. Also, these failures had the potential for residents to receive the wrong caloric intake and not meet the nutritional needs of the residents, which could further compromise their medical status. The resident census was 77. Findings: 1. During a review of the facility's Menu - Week 3, Day 17 Tuesday (3/21/23), dated 6/26/2021, the menu indicated a serving size of 1 cup (8 ounces) of zucchini, for residents on a Heart Healthy and Low Sodium diet. The menu further indicated the serving size of mashed potatoes is ½ cup (4 oz.) for all diets (regular, consistent carbohydrate are examples). a. During an observation of lunch meal service on 3/21/23, starting at 11:22 a.m., [NAME] served residents mashed potatoes using a three-ounce scoop for residents on the regular and consistent carbohydrate diets. During an interview on 3/21/23, at 11:43 a.m., with Cook, [NAME] confirmed she was using a three ounce scoop to serve the mashed potatoes. During a review of the facility Census Report from CBORD (electronic menu system in the facility kitchen), dated 3/21/23, showed 17 residents on the regular diet (Resident 52, 2, 51, 49, 41, 24, 48, 10, 62, 127, 130, 132, 133, 135, 621, 622, 625, 58 and 16 residents on the Consistent Carbohydrate diets (Resident 36, 27, 25, 22, 53, 8, 56, 66, 23, 122, 125, 126, 128, 131, 623, 628). b. During an observation of the lunch meal service on 3/21/23, starting at 11:22 a.m., [NAME] served residents ½ cup (4 ounces) of zucchini with a four-ounce spoodle (type of serving spoon). FSW 3 was designated as the starter. FSW 3 was observed preparing the meal tray by placing cutlery and napkins on the tray. Additionally, the responsibility of the starter position was to verbally communicate the physician ordered diet to the cook as well as any food dislikes/preferences for the entrée plate. It was noted FSW 3 did not accurately communicate the diet order. As an example, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 5 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 - Many for residents with a physician ordered regular texture, consistent carbohydrate diet (a diet used to treat diabetes) FSW 3 did not communicate the consistent carbohydrate diet component, rather the information transmitted to the cook was limited to the regular texture as well as any pertinent likes/dislikes. During an interview on 3/21/23 at 12:05 p.m. with the Food Service Manager (FSM), FSM confirmed that the heart healthy diet should get one cup zucchini not ½ cup. During an interview on 3/21/23 at 12:12 p.m., with Cook, [NAME] confirmed she was serving four ounces of zucchini or green beans (an alternate vegetable if residents did not like zucchini). During a review of the facility Census Report from CBORD, dated 3/21/23, showed 15 residents on the heart healthy or low sodium diets (Resident 33, 14, 46, 25, 38, 42, 7, 20, 6, 121, 123, 124, 129, 134, 627). During an interview on 3/21/23, at 3:43 p.m., with FSM, she stated her expectation is the menu is followed. 2. During an observation of the lunch meal service on 3/21/23 starting at 11:22 a.m., test tray meals were ordered from the kitchen. One regular meal tray and one puree meal tray. The regular meal tray received chicken [NAME], mashed potatoes, zucchini and peach crisp. The puree meal tray received a pureed chicken mold, mashed potatoes, pureed green bean mold and chocolate pudding. During a review of the lunch menu Day 17 for 3/21/23, showed the regular diet to get chicken [NAME] + sauce, mashed redskin potatoes, zucchini, and peach crisp. The puree diet showed puree chicken, mashed potatoes, puree green beans and chocolate pudding. During an interview while conducting a tasting of the test trays with FSM, on 3/21/23 at 12:50 p.m., FSM acknowledged the puree mold with [NAME] sauce didn't taste as good as the regular chicken [NAME] and that the flavor was not as good. She stated she wanted to puree the regular food but she was not able to change the menus. FSM acknowledged there was not as much variety in the puree menus and those residents are a vulnerable population. During an interview on 3/22/23, at 9:02 a.m., with Resident 19 and an interpreter (CNA 1), Resident 19 stated he gets the same thing every day. During a review of the facility's Menu - Week 3, dated 6/26/2021, Day 15 to Day 21 showed, pureed omelet for breakfast six out of seven days a week. The pureed green bean mold, mashed potatoes and puree carrot mold was served on six out of seven days a week. During a further review of the facility's Menu - Week 1, dated 6/26/2021, Day 1 to Day 7 showed, the pureed omelet for breakfast was served daily, seven days a week Pureed green bean mold was served once a day for five out of seven days ., The pureed carrot molds are served daily on four out of seven days. During a further review of the facility's Menu - Week 2, dated 6/26/2021, Day 8 to Day 14 showed, pureed omelet four out of seven days a week. The pureed green bean mold and pureed carrot mold were served on three out of seven days. The pureed vegetables on the 21 Day menu were: green beans, carrots, broccoli, peas and the pureed butternut squash was served once. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 6 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 document titled, Regular Diet, the document indicated in part, healthful nutrition from a variety of foods . a variety of fresh, frozen, and canned (unsalted) whole vegetables . 3. During a review of the facility's Menu - Week 3, Day 17 Tuesday (3/21/23), dated 6/26/2021, showed the regular diet to get chicken [NAME] + sauce, mashed redskin potatoes, zucchini, and peach crisp. Residents Affected - Many During an interview on 3/22/23, at 12:06 p.m., with FSM , FSM confirmed menus had not been updated since 2021. FSM stated menus should be updated periodically to meet the nutritional needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 7 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure food was prepared in a form to meet the individual needs of a resident, Resident 33. Residents Affected - Few This failure had the potential to result in choking and aspiration (food or liquid is breathed into the lungs, instead of being swallowed) in a resident with difficulty swallowing. Findings: During a concurrent observation and record review in the kitchen, on 3/21/23, at 12:14 p.m., Resident 33's meal ticket indicated SB6 (Level 6 Soft & Bite Sized Dysphagia Diet (ordinary foods that are soft and easy to chew), the cook plated a whole jumbo size hot dog and bun for Resident 33, who was on a Dysphagia (problems swallowing) Diet. During a review of Resident 33's Order Sheet (OS), dated 2/21/23, the OS indicated, Level 6 Soft & Bite Sized Dysphagia Diet . Chopped Dysphagia Diet During an interview on 3/22/23, at 3:00 p.m., with Registered Dietitian (RD), RD stated, the cook should be following the diet order and a jumbo hot dog should not have been served whole, it should have been chopped. The RD stated the resident does not have teeth so prefers things cut up so he can eat it better. During a review of facility's document from the facility Diet Manual, undated, the document indicated in part, . A diet used in the dietary management of dysphagia with food texture modification described as soft, tender, moist . foods should have a particle size no greater than 15mm in length by 15mm width for adults. The document further indicated, Foods Not Recommended Protein foods in sizes larger than 1.5cm x 1.5cm pieces . Sausage skin. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) website, https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/6_Soft_Bite_Sized_Adult_consumer_handout_30Jan2019.p accessed on 3/29/23, indicated, Level 6 - Soft & Bite-Sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft & Bite-Sized foods need a moderate amount of chewing, for the tongue to 'collect' the food into a ball and bring it to the back of the mouth for swallowing. The pieces are 'bite-sized' to reduce choking risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 8 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Kitchen staff failed to monitor cool down procedure for potentially hazardous foods. 2. The scoop handle in the bulk oatmeal bin, had oatmeal in the handle. 3. Dented cans were not removed from the dry food storage room. 4. There were undated, thawed health shakes in the nourishment refrigerator. These facility failures had the potential to result in the growth of microorganisms and the potential for foodborne illness in a vulnerable resident population. Findings: 1. a. During the initial kitchen tour observation on 3/20/23, starting at 9:32 a.m., the reach in refrigerator had one container of previously cooked mashed potatoes dated 3/19 use by 3/21 with an internal temperature of 55 degrees Fahrenheit (F), one container of previously cooked diced potatoes dated 3/20 use by 3/23 with an internal temperature of 84.6 degrees F, and one container previously cooked pasta, dated 3/18 used by date 3/20, with an internal temperature of 41.7 degrees F, and a container of tomato soup dated 3/18 use by 3/20 with an internal temperature of 40 degrees F. A concurrent interview at this time with the Cook, [NAME] stated we used the diced potatoes for breakfast, she put them in the refrigerator at 8:30 a.m. and sometimes we use the potatoes again later. During an observation on 3/20/23, at 10:43 a.m., the reach in refrigerator had one container of previously mashed potatoes dated 3/19 use by 3/21 with an internal temperature of 52.3F, one container of previously cooked diced potatoes dated 3/20 use by 3/23 with an internal temperature of 76.1F, and one container of tomato soup dated 3/18 use by 3/20 with an internal temperature of 40F. During an interview on 3/20/23, at 10:45, with Cook, [NAME] verified the cool down procedure was not used for foods that require Temperature Control Safety (TCS). The [NAME] stated only meats are cooled, and not vegetables or potatoes. The [NAME] was not able to verbalize the proper cooling procedure, or temperatures, for cooling potentially hazardous food. During an interview on 3/20/23, at 10:43, with Registered Dietitian (RD), RD stated cool down process will be done on all cooked foods and was not aware cool down was only being done on meat. During an interview on 3/20/23, at 10:48 a.m., with Food Services Manager (FSM), FSM stated cool down should have been done on the potatoes, and the soup. FSM stated the items should be discarded. During a review of the cooling logs, hung on the reach in refrigerator, showed there were no foods written on the log. During an interview on 3/20/23 at 11:53 a.m. with the FSM, she confirmed that no cooling logs from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 9 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 December to current. FSM stated they know what the problem is now and are working to correct it. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Cooling Food, dated 2021, the P&P indicated in part Food should be cooled from 135 to 70 degrees within 2 hrs., from 70 to 141 degrees within 4 hrs., (with a total [NAME] time of 6 hrs. or less). Residents Affected - Many During a review of the facilities In-Service documentation title The Flow of Food: Preparation, undated, the document indicated in part . Cooling Food - Pathogens grow well in the temperature danger zone. The grow much FASTER between 125F and 70F. Food must pass through this temp range quickly to reduce pathogen growth. Cool TCS food from 135F to 41F or lower with 6 hours. b. During the initial kitchen tour observation on 3/20/23, starting at 9:32 a.m., the reach in refrigerator across from the FSM office, there was a container of tuna salad dated 3/19 use by 3/21 with an internal temperature of 41 degrees F, and a container of chicken salad dated 3/19 use by date 3/21 with an internal temperature of 40.3 degrees F. During an interview with Food Service Worker (FSW 4) on 3/22/23 at 10:59 a.m., FSW 4 stated her job is to make the tuna, chicken and egg salad. FSW 4 stated when she makes the tuna salad, she will get the tuna from the dry storeroom and the mayo is usually in the fridge. FSW 4 stated she will make the salads following directions from the recipe then will put them in the fridge or make sandwiches with them. FSW 4 confirmed she does not take a temperature of those foods after she makes them or before they are put in the refrigerator. During an interview with the FSM on 3/22/23 at 12:06 p.m., the FSM acknowledged there was no monitoring of the cooling of ambient/room temperature foods being done. FSM acknowledged there were no foods on the cooling logs, and they will be working on that. During a review of the facility's policy and procedure (P&P) titled Cooling Food, dated 2021, the P&P indicated 2. Food prepared with room temperature food could be cooled to 41 degrees F within 4 hours. 2. During a concurrent observation and interview on 3/20/23, at 10:00 a.m., with Food Service Worker (FSW) 1 in the presence of the FSW and the RD, the contents in the dry storage room were observed. The scoop in the bulk oatmeal container had oatmeal inside the handle. FSW 1 confirmed the bin was too full and the scoop should not be touching the food of the container. RD stated they needed to not fill the container as high with oatmeal and they needed to remove the scoop. RD stated food should not be touching the scoop handle. During a review of the 2022 Federal Drug Administration (FDA) Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: . in the food with their handles above the top of the food and the container. 3. During a concurrent observation and interview on 3/20/23, at 10:00 a.m., with FSW 1, in the dry storage room, there were four #10 (approximately 109 ounces) cans of mandarin oranges, unopened, dented, and available for use. There was one large, unopened, dented can of caramel topping available for use. FSW 1 verified the dented canned food items should not have been on the shelf and available for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 10 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 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 - Many During a review of the facility's P&P titled, FNS (Food & Nutrition Services) receiving, undated, the P&P indicated in part, FNS staff also refuses products damaged . or dented. Make sure that staff understand that if product appears damaged or mislabeled that it should not be accepted and logged correctly. 4. During an observation on 3/20/23, at 12:34 p.m., in Wing 200, there were two 4-ounce cartons of thawed chocolate mighty shakes in the nourishment refrigerator. The containers were unlabeled and undated. During an interview on 3/20/23, at 12:53 p.m., with FSW 1 in Wing 200, FSW 1 confirmed mighty shakes should not be stored in the refrigerator. FSW 1 stated, they shouldn't be there. During a review of the manufacture's guideline on the label of the mighty shake container, the label indicated, Store Frozen. Thaw at or below 40F. Use thawed product within 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 11 of 12 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 555236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marian Regional Medical Center D/P Snf 1530 East Cypress Way Santa Maria, CA 93454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure monitoring for signs and symptoms of bleeding was documented in the clinical record for one of two sampled residents (Resident 58) on the anticoagulant Apixaban (a medication that decreases the blood's ability to clot). This failure had the potential for Resident 58's response to the medication to result in assessments that were inaccurate which could affect care and services rendered to the resident. Findings: During a review of Resident 58's, Physician Note, dated 11/22/22, the note indicated, Assessment/ Plan .Atrial fibrillation (quivering of the heart) .acute, now stable, with history of sinus chronic tachycardia (increased heart rate) .Continue Eliquis (brand name for Apixaban) 5 milligrams (mg) twice daily (BID) for anticoagulation. During a review of Resident 58's, Active Order Profile, dated 11/9/22, there was a medication order which indicated, Apixaban (Eliquis) 5 mg by mouth (PO), BID, priority: Routine, Indication: blood clot prevention. The medication triggered a system-generated order, dated 11/9/22, which indicated, Rx Monitoring Anticoagulants .Monitoring for Apixaba. During a concurrent interview and record review, with a licensed nurse (RN 2), on 3/22/23 at 3:52 p.m., Resident 58's clinical records were reviewed. RN 2 verified Resident 58 was on Apixaban and a baseline care plan to monitor the resident for signs and symptoms (s/s) of bleeding was in place. RN 2 verbalized staff assessed Resident 58 daily for s/s of bleeding but could not provide the documentation of monitoring when requested. RN 2 further verbalized staff would only document in the record if Resident 58 had an actual bleeding episode, i.e., a change in the resident's condition, otherwise, it was not documented when there's none. RN 2 acknowledged there was no proper documentation of Resident 58's monitoring for s/s of bleeding and should have been. During a review of the facility's, policies and procedures (P&P), titled, Documentation of the Implementation of the Plan of Care Policy 8620-13, dated 1/23, the P&P indicated, Policy .Interdisciplinary members' responsibilities include, but are not limited to: 1) Development of a baseline care plan that is based on the initial assessment of each resident by nursing staff and or interdisciplinary team member/s .a) Be developed within 48 hours of a resident's admission, b) Include the minimum healthcare information necessary to properly care for a resident . including but not limited to .physician orders, c) Upon completion of the baseline care plan .written summary .includes but is not limited to: the initial goals of the resident, a summary of the resident's medication and dietary instructions, any services and treatments to be administered by the facility. During a review of the facility's, P&P, titled, Documentation - MECC 8721-10, dated 2/17, the P&P indicated, Nursing Practice Standard .The staff will document patient care as directed .1) The staff documentation may include but is not limited to the following: assessments/evaluations, patient care plan, interventions provided, the patient's response and the outcome of the interventions. During a review of the facility's P&P titled, Medication/Treatment Administration 8721-13, dated 12/20, the P&P indicated, Tests and taking of vital signs, upon which administration of medications or treatments are monitored, will be performed as required and the results recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 12 of 12