Health inspection·February 15, 2024

F 0637 facility care to address mental health needs. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 2/14/24 at 10:48 a.m. with a licensed nurse (LN2), Resident 61's MDS dated [DATE], Letter dated 5/5/2023 and Report dated 5/5/2023 were reviewed. LN2 stated, A significant change [comprehensive assessment] should have been done but was not. Residents Affected - Few During a review of the Center's for Medicare & Medicaid Services user manual for the comprehensive assessment (User Manual) titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, the User Manual indicated, Significant Change in Status Assessment (SCSA) . The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [Interdisciplinary Team of health care professionals] has determined that a resident meets the significant change guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 2 of 14 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 02/15/2024 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 two of six sampled residents (Residents 6 and 61): Residents Affected - Few 1. For Resident 6, a person-centered interdisciplinary team nutrition care plan (IDTNCP - detailed plans of care created by representatives from several medical disciplines or specialties) was developed to include resident's goals and preferences, clear measurable objectives, and resident specific nutrition interventions. This failure resulted in unclear measurable weight gain goal and lacked resident specific dietary instructions which impedes the IDT from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure nutrition care needs would not go unrecognized and unmet. (Cross Reference F806) 2. For Resident 61, a musculoskeletal care plan (relating to bones, muscles, joints, tendons and ligaments that support the body when it moves around) included interventions (an action taken to improve a disorder) that were person-centered (care specific to Resident 61's needs). This failure had the potential to result in an avoidable fall. Findings: 1. During a concurrent interview and record review on 02/14/24 at 3:19 p.m. with Registered Dietitian (RD), Resident 6's admission Nutrition Services Assessment (NA), dated 11/30/23 was reviewed. The NA indicated, Resident 6 had severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). RD stated Resident 6's daily calorie needs were assessed to promote weight gain and an appetite stimulant was ordered to aide with weight gain. NA indicated, Resident 6's weight was 84 pounds (lbs) as of 11/23/23. RD stated the ideal body weight (IBW) listed on the NA of 52.38 kg (kilograms - a unit of mass equivalent to 115 lbs) was automatically populated by the software used for the electronic health record (EHR) and was not used in the plan of care for Resident 6, nor discussed with Resident 6. RD stated there was no documentation related to a goal weight for Resident 6. NA indicated, Nutrition Care Plan, Dietitian's Recommendations: 1. Diet adjusted to regular-chopped meat . 2. Ensure [an oral liquid nutrition supplement to add calories and protein] BID [two times a day] B/L [breakfast, lunch], 3. Honor pt [patient] preferences, 4. Appetite stimulant usage to encourage PO [food by mouth] intake, 5. Wts [weight] as ordered, 6. Monitor intakes [quantity of food/beverage consumed], skin and pertinent labs, POC [plan of care] to be adjusted as needed. During a concurrent interview and record review on 02/14/24 at 3:24 p.m. with RD, Resident 6's LTC [long term care] Nutritional Status IPOC [interdisciplinary plan of care] (IDTNCP), initiated [activated] on 11/30/23, was reviewed. IDTNCP indicated, Weight change more than 5% [percent] in 1 [one] month, . Encourage snacks between meals and with activities, Supplements as ordered, Monitor weight as ordered, Obtain and honor food preferences, Food preferences reviewed and updated, Consult to dietitian for -2.2 kg [minus five lbs] weight loss . RD stated the listed outcome of weight change more than 5% in 1 month meant the facility did not want the resident to lose weight of 5% in 1 month. RD stated, the IDTNCP was not person-centered as Resident 6 had recently lost significant weight of 5% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 3 of 14 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 02/15/2024 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 Residents Affected - Few in one month during a previous admission and could not afford to lose weight due to her underweight status, and protein calorie malnutrition. RD stated it would be important to identify weight loss in Resident 6, and address, prior to becoming a significant weight loss. RD stated the goal was for Resident 6 to gain weight. RD stated, the IDTNCP had not indicated the plan for weight gain, there was no goal weight determined and she had not discussed what a reasonable goal weight would be with Resident 6. RD verified the IDTNCP was not person-centered and had not reflected a measurable goal related to facility's nutrition plan of care for resident to gain weight. During a concurrent interview and record review on 02/14/24 at 3:26 p.m. with RD, Resident 6's Dietitian Note (DN), dated 1/11/24, indicated, CHMT modifier [chopped meat] r/t [related to] pt inability to easily cut meats ., no difficulty chewing or swallowing foods. Pt c/o [complaint of] not receiving deli meat sandwiches or pulled pork sandwich, possibly r/t CHMT modifier. RD messaged ST [speech therapist] to evaluate pt ability. RD will coordinate with kitchen to allow pt to receive finger foods [food served in such a form that it can conveniently be eaten with the fingers] as is, as tolerated ., RD observed pt difficulty holding water cup. Will add sippy cup TID [three times a day] with all meals . Resident 6's DN, dated 2/7/24, indicated, Continues to tolerate regular diet + CHMT modifier (entrée, whole meat finger foods OK). RD stated that meant the entree should have chopped meat, however resident could have a sandwich or a burger, for example, intact not chopped. RD stated there was no documentation on Resident 6's IDTNCP indicating a sippy cup would help Resident 6 be able to consume beverages, or that Resident 6 had a regular chopped meat diet order but was allowed to have finger foods, or whole meat for sandwiches, to aide in honoring resident food preferences. RD stated, the IDTNCP was not person centered to reflect resident specific details in order to communicate to IDT about changes that impacted Resident 6's nutritional status. During a concurrent interview and record review on 02/15/24 at 10:26 a.m. with Director of Nursing (DON), Resident 6's IDTNCP, initiated [activated] on 11/30/23, was reviewed. DON verified Resident 6's IDTNCP had not contained measurable objectives and was not resident centered care when the care plan lacked resident specific, detailed, interventions and resident preferences. DON stated the software used for the EHR automatically populates care plans with specific verbiage when triggered. DON stated the facility needed to work on tailoring the care plans to be resident specific, with measurable objectives, for person centered care. During a review of the facility's policy and procedure (P&P) titled, Documentation of the Implementation of the Plan of Care, dated 7/23, the P&P indicated, Purpose: The implementation of person centered care management is the responsibility of an interdisciplinary team (IDT) .the initial plan that includes but is not limited to: a. The initial goals of the resident, b. A summary of the resident's medication and dietary instructions, c. Known services and treatments to be administered by the facility and personnel acting on behalf of the facility, d. Updated information based on the details of the comprehensive plan of care, if applicable. During a review of the facility's P&P titled, Weights and Heights, dated 1/24, the P&P indicated, Purpose: To obtain pertinent patient data to develop a person centered plan of care. 2. During a review of Resident 61's Physician Note (PN), dated 2/7/24, the PN indicated, Resident 61's had diagnoses including left below-knee amputation (leg below the knee surgically removed) and right hemiparesis (one sided weakness). During a review of Resident 61's Minimum Data Set ((MDS) a standardized assessment and care screening tool), dated 12/28/2023, the MDS at Section GG indicated, Resident 61 was dependent on staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 4 of 14 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 02/15/2024 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 Residents Affected - Few be able to roll from lying on back to left and right side on the bed, to move from sitting on side of bed to lying flat on the bed, to transfer to and from a bed to a chair or wheelchair, to get on and off a toilet or commode, and to get in and out of a tub/shower. During a review of Resident 61's Musculoskeletal Care Plan ((CP) a summary of health conditions, specific care needs, current treatments, and identifies which healthcare discipline is responsible for providing the care needed), last updated 11/3/2023, the CP indicated, Provide Appropriate Level of Assistance with Transfer as Indicated. During a concurrent interview and record review on 2/15/2024 at 10:40 a.m. with a licensed nurse (LN3), Resident 61's CP and MDS were reviewed. LN3 agreed the intervention to provide appropriate level of assistance with transfers did not indicate the level of assistance Resident 61 required. LN3 stated the CP was not resident specific and it should have been. During a review of the facility's policy and procedure (P&P) titled, Documentation of the Implementation of the Plan of Care, dated 7/23, the P&P indicated, Development of a comprehensive plan of care is based on the initial assessment of each resident by the nursing staff and/or IDT members and includes the necessary information to ensure the safety and well-being of the resident . An IDT Care Conference will be held within 14 days of admission, quarterly thereafter, and/or at the time of significant change of condition to review assessments, interventions and goals of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 5 of 14 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 02/15/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review, the facility failed to ensure an entrapment risk assessment (an assessment to evaluate and monitor a patient's risk for getting entangled on a bed rail) was completed and an informed consent (a process in which a healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or treatment) was obtained prior to the use of bed rails for one of 18 sampled residents (Resident 21). These failures do not support optimal bed safety which could potentially place Resident 21 at risk for entrapment and serious injury. Findings: During an observation on 2/12/24 at 11:52 a.m., Resident 21 was observed sleeping in a large specialty bed with a low air loss mattress (a pressure-relieving mattress used to prevent skin breakdown). The head of the bed was slightly elevated and all four bed rails were up. During a review of Resident 21's Physician Notes (PN), dated 2/5/24, the PN indicated in part, Resident 21 had a history of severe traumatic brain injury from a motor vehicle accident in 2012, resulting in quadriplegia (paralysis of both upper and lower limbs), mutism (inability to speak), seizure disorder, and dependence on gastric tube (G-tube - a way of providing nutrition directly to the stomach with the use of a long, flexible tube inserted through the abdomen) feeding. During a concurrent interview and record review, on 2/13/24 at 12:22 p.m., with a licensed nurse (LN 1), Resident 21's Electronic Medical Record (EMR), was reviewed. LN 1 stated Resident 21's quadriplegic condition required him to be in a specialty bed. LN 1 stated that the lower bed rails kept the mattress from sliding down. LN 1 also mentioned there were numerous occasions where staff had to pull Resident 21 back to preferred position because the mattress slid too much. LN 1 confirmed an informed consent was required for having all four bed rails up, but could not locate in Resident 21's EMR documentation that a consent was signed by Resident 21's responsible party (RP - person designated to make healthcare decisions on behalf of a patient) for the use of all four bedrails. LN 1 was also unable to locate documentation that an entrapment risk assessment was done for Resident 21. During an interview on 2/14/24 at 12:20 p.m., with the Director of Nursing (DON), DON stated Resident 21 has been using the specialty bed for about five years now but could not recall whether a consent was obtained, or an entrapment risk assessment done. DON was informed that a review of Resident 21's EMR, together with LN 1, did not contain documentation that an informed consent was signed, nor an entrapment risk assessment was done. DON acknowledged that these documents should have been completed. During an interview on 2/14/24 02:25 p.m. with Resident 21's RP, the RP stated not receiving information about bed rails on the days following Resident 21's admission to the facility. Resident 21's RP verbalized that staff just now informed her about the bed rails and was instructed to sign the consent. During a review of the facility's policy and procedures (P&P) titled, Restraints, dated 8/21, the P&P indicated in part, Lower side rails being used as enablers . no order will be obtained, however, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 6 of 14 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 02/15/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm informed choice regarding the enabler will be obtained. The P&P indicated further, Education of the resident of the risks associated with the use of lower side rails will occur when they provide additional safety measure although it is not medically indicated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 7 of 14 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 02/15/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview and record review, the facility failed to ensure the Food Service Manager (FSM) demonstrated skills sets to carry out the functions of the food and nutrition service when: Residents Affected - Many 1. Dietary staff were not trained on monitoring, and documenting, wash water temperature for the high temperature dish machine in accordance with manufacturer's guidelines and facility policy and procedure. 2. There was not a system, to include a policy and procedure, to guide staff on the requirement to purchase pasteurized shell eggs to have readily available in order to honor a resident's request for an undercooked egg, such as sunny side up eggs, in a safe manner for Resident A (confidential resident). This failure resulted in an inadequate monitoring system for the wash water temperature of the high temperature dish machine to ensure dishes used by the residents would be clean before being sanitized to allow the sanitizer (high temperature of 180 degrees Fahrenheit [F] for rinse cycle) to achieve its maximum benefit. In addition, the facility failed to honor Resident A's request for a runny egg due to lack of purchasing pasteurized shell eggs which would have allowed for resident preference while maintaining food safety. Findings: 1. During an observation on 2/12/24 at 10:56 a.m. in the kitchen, the facility used a high temperature dish machine (heat sanitization) in which the manufacturer's data plate with directions affixed to the dish machine indicated minimum wash temperature of 150 degrees F and minimum rinse temperature of 180 degrees F. During concurrent interview and review on 2/12/24 at 10:56 a.m. with FSM, the manufacturer's data plate for the high temperature dish machine was reviewed. FSM stated, a monitoring system was in place to ensure rinse temperature would meet 180 degrees F for sanitizing but there was not a monitoring system in place to ensure the wash water temperature would reach 150 degrees F. FSM acknowledged without a system to monitor the wash water temperature the staff would not be able to identify when it was out of range to report the problem for a solution. During a concurrent interview and record review on 2/13/24 at 4:00 p.m. with FSM the facility's policy and procedure (P&P) titled, IC137: Food Nutrition Services (FNS) Dish Machine Documentation of Temperatures, dated [undated] was reviewed. The P&P indicated, 1. Dish machine wash and rinse temps must be maintained based on manufacturer guidelines . 3. Document temperature. Reconcile temperatures out of range. Ensure staff is in-serviced on how to address out-of-range temperatures . 5. Stop using dish machine if out of range . FSM stated, the dish machine policy and procedure was not followed, and stated, I'm not going to argue that because it wasn't followed. During a review of facility's job description (JD) titled Manager of Nutrition Services-Patient Services (JD), dated [undated], the JD indicated, Job Summary-Responsible to maintain and administer dietary and nutrition services and to provide for the operational needs of staff . Job Responsibility 1- Directs all patient interactive positions (i.e., dieticians, diet clerks, etc.) and provides for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 8 of 14 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 02/15/2024 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 0801 the operational needs of these positions. Maintains regulatory compliance and infection control practices. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Many 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, Manufacturers' Operating Instructions) 2. During concurrent observation and interview on 2/12/24 at 10:00 a.m. with FSM in the walk-in refrigerator, there seemed to be no availability of pasteurized shell eggs. FSM was asked where the pasteurized shell eggs were stored, and FSM stated, We only have these eggs and pointed to a bag of pasteurized liquid eggs and also showed a bag of hard-boiled eggs that was purchased already boiled from the vendor. FSM verified those were the only type of eggs purchased by the facility, and FSM stated the facility does not purchase pasteurized shell eggs. FSM stated, their menu did not have the need for pasteurized shell eggs. FSM was asked if they have had a resident request a sunny side up or soft fried egg and FSM stated on occasion, but we do not have pasteurized shell eggs, so we do not prepare them. FSM was asked how she handles a resident's request for a soft fried egg, or sunny side up egg and FSM said they do not prepare them for the resident and instead they redirect the resident to a menu called Personal Choices. During an interview on 2/13/24 at 11:09 a.m. with Resident A during the confidential Resident Council meeting, Resident A stated, that she has asked for a medium well egg and the yolk was completely cooked when it should be a little runny. During a review of Center for Clinical Standards and Quality/Survey and Certification Group- . Interpretive guidance and Procedures for Sanitary Conditions, Preparation of Eggs in Nursing Homes, dated 5/20/2014, indicated, Pasteurized shell eggs are commercially available, are clearly labeled and allow the safe consumption of undercooked eggs. Federal regulation expect nursing facilites to make reasonable efforts to respect resident choices and can honor resident choice while maintaining health and safety standards through the use of pasteurized eggs. During a review of Job Description Manager of Nutrition Services-Patient Services (JD), dated [undated], the JD indicated, Job Responsibility 4- Actively collaborates in the process of menu development for patient, cafeteria, and catering services. Manages facility diet manual, as well as patient diet and nutritional analysis compliance with the diet manual. During a review of the facility's policy and procedure (P&P) titled, Cooking Cold Prep Foods, dated 2019, the P&P indicated, 4. Unpasteurized eggs if used at facility, must reach internal temp [temperature] of 160 degrees F [fahrenheit] for 15 seconds . 5. Pasteurized eggs do not need cooking to 145 degrees for 15 secones. But must be used immediately after cooking . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 9 of 14 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 02/15/2024 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 Residents Affected - Few 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 that food was prepared in a form to meet resident needs for one of 18 sampled residents (Resident 67), when a minced and moist diet was served as a pureed diet. This failure had the potential for risk of weight loss for Resident 67. Findings: During an interview on 2/12/24 at 11:50 a.m. with Resident 67's responsible party (RP), RP stated, current diet was pureed per the dietitian's recommendation as the dietitian observed swallowing difficulty. During a concurrent observation and interview on 2/13/24 at 10:42 a.m. with the [NAME] in the kitchen, in the presence of Food Service Manager (FSM), the cook placed carrots in a food processor, and when finished, the carrots appeared to be pureed. Then the [NAME] stated, I'm going to make puree carrots next, and stated those were the minced and moist carrots. During an observation on 2/13/24 at 11:55 a.m. in Resident 67's room, with RP, Resident 67's lunch meal appeared to be pureed and was observed to have liquid separation and RP stated it was pureed. A picture was taken of Resident 67's lunch meal after RP stated Resident 67 was not going to eat the lunch provided by the facility. During an interview on 2/14/24 at 2:23 p.m. with Speech Therapist (ST) and Director of Nursing (DON), ST read the ST evaluation notes dated 1/12/24, 1/17/24 and 1/23/24 and summarized the notes and stated, It's two parts, the resident does have some swallowing trouble as indicated in the ST notes and it's cognition. The resident had been evaluated by ST and went from regular diet to SB 6 (Soft and Bite Sized) on 1/12/24 and to minced and moist level 5 on 1/17/24. ST looked at the picture of Resident 67's lunch meal served on 2/13/24 and ST stated, the chicken was minced and moist and not the rest. DON verified the picture of resident's lunch meal tray served on 2/13/24 of chicken, carrots, pasta and DON stated it looked like puree texture. During a review of Resident 67's Doctor Orders, dated 1/17/24, the Doctor Orders indicated, Level 5 Minced and Moist Dysphagia Diet (MM5). During a concurrent observation and interview on 2/14/24 at 2:25 p.m. with FSM, FSM observed the picture of Resident 67's lunch meal from 2/13/24 and FSM stated the food did appear more like puree than minced and moist and verified there was separation of thin liquids which was not allowed with a minced and moist diet. FSM stated, the lunch served to Resident 67 was a puree texture and should have been minced and moist per Resident 67's diet order. During a review of Level 5 Minced and Moist Dysphagia Diet (MMD)-Diet Manual, dated [undated], the MMD indicated, This diet is prescribed to people who are unable to bite foods, have pain or difficulty chewing foods, or become easily tired when chewing foods. This diet requires a texture modification so that food are minced, soft, and moist and can be scooped and easily shaped into a ball . No separation of thin liquids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 10 of 14 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 02/15/2024 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 During a review of facility's policy and procedure (P&P) titled, PC090 FNS Menus, Policies, Medical Therapeutic Diets and Diet Manual (DM), dated [undated], P&P indicated, FNS [Food & Nutrition Services] leader in collaboration with the RD [Registered Dietitian] leader or dietician designee oversee the review of menus, policies, procedure, medical therapeutic diets, and diet manual. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 11 of 14 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 02/15/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 6) food preferences were honored in a timely manner. Residents Affected - Few This facility failure to honor Resident 6's food preferences in a timely manner could diminish appetite, caloric intake and promote continued weight loss. Findings: During a concurrent interview and record review on 02/14/24 at 3:19 p.m. with Registered Dietitian (RD), Resident 6's admission Nutrition Services Assessment (NA), dated 11/30/23 was reviewed. The NA indicated, Resident 6 had severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). RD stated Resident 6's daily calorie needs were assessed to promote weight gain and an appetite stimulant was ordered to aide with weight gain. NA indicated, Pt [patient] denies difficulty chewing/swallowing . Nutrition Care Plan, Dietitian's Recommendations: .Honor pt [patient] preferences . During a concurrent interview and record review on 02/15/24 at 09:15 a.m. with RD, Resident 6's Dietitian Note (DN), dated 1/11/24, was reviewed. DN indicated, CHMT modifier [chopped meat] r/t [related to] pt inability to easily cut meats ., no difficulty chewing or swallowing foods. Pt c/o [complaint of] not receiving deli meat sandwiches or pulled pork sandwich, possibly r/t CHMT modifier. RD messaged ST [speech therapist] to evaluate pt ability. RD will coordinate with kitchen to allow pt to receive finger foods [food served in such a form that it can conveniently be eaten with the fingers] as is, as tolerated . RD stated, a Nutrition Services Communication, dated 1/12/24, was completed on 1/12/24 based on the ST's assessment that indicated, CHMT entree, pt OK to have whole meats for finger food options such as sandwiches . RD stated, the Nutrition Services Communication automatically prints out in the dietary services department in the kitchen. During a review of Resident 6's Active Order Profile (OP), dated 1/12/24, the OP indicated, Start Date: 1/12/24, Orderable: Nutrition Services Communication .Details/Comments; CHMT entree, pt OK to have whole meats for finger food options such as sandwiches ., Status: Ordered. During a review of the facility ' s policy and procedure titled, Hybrid Menu Selection, dated 2019, the P&P indicated, If personal choice in compliance with patient's diets, diet clerk will complete change in menu request. Diet clerk will enter change on PC028 menu substitution log. During a concurrent interview and record review on 02/15/24 at 09:20 a.m. with RD, Resident 6's F/U [follow up] Food Preferences (FP) noted by the Food Services Manager (FSM), dated 1/26/24, was reviewed. The FP indicated, [Name of resident] wanted to know why she could not get a turkey or ham sandwich. I stated that her diet order may be preventing her from getting them. I just reviewed Meal IQ [software program in dietary department] and with her diet order, Meal IQ does not allow these sandwiches. I did order a chicken salad sandwich for her for her 1500 [3 p.m.] snack time. [Name of resident] also requested brownies that she does not receive also because of her diet order. I will reach out to facility RD for her to f/u with SLP [speech language pathologist] for a screen to see if [name of resident] diet can be upgraded. RD stated it seemed like the kitchen [staff] was not aware the resident could have sandwiches, and the resident's food preferences for sandwiches was not honored. RD stated there was a delay in honoring the resident's food preferences which could impact caloric (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 12 of 14 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 02/15/2024 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 0806 intake and contribute to further weight loss. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 6's DN, dated 2/7/24, indicated, .noted -2.2kg/5.5% loss [five percent loss of body weight] x < 1 month [less than one month] ( .not beneficial) .Continues to tolerate regular diet + CHMT modifier (entr&eacute;e, whole meat finger foods OK). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 13 of 14 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 02/15/2024 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 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 food was consistently dated in the kitchen in one of three chilling (refrigerator/freezer) units. Residents Affected - Few This failure had the potential to affect food quality and/or food safety, and would not provide a mechanism to ensure the facility's shelf life guidelines could be followed. Findings: During a concurrent observation and interview on 2/12/24 at 10:10 a.m. with Food Service Manager (FSM), in the walk in freezer, there were two bags (packed from manufacturer) of pieces of chicken and one bag of the chicken pieces was opened and not dated, the other bag was unopened and not dated. Two large, ten pound, uncooked frozen turkeys located on the shelf were undated. Four tubes of uncooked beef were undated. FSM verified, they were not dated, and FSM stated, frozen foods should have been dated when placed in the freezer, and should have been dated once opened, as without a date the facility's freezer storage shelf-life policy and procedure could not be followed. During a review of the facility's policy and procedure (P&P) titled, PC017: Frozen Storage, dated [undated], P&P indicated, Freezer Storage-Expiration dates printed by the manufacturer apply until the product is open. Once opened, use these time limits unless manufacturer's date is earlier. The day of delivery and opening/preparation counts as Day 1. Shelf life of frozen storage without the manufacturer date unopened is 1 year unless the manufacturer's date is earlier. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 14 of 14