Health inspection·April 8, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure that the grilled cheese sandwich, provided as an alternative meal option, was of similar or nutritive value to the scheduled entrée when residents (Residents 5, 9, 62) requested a different meal choice. This resulted in resident's not being provided equal nutritive value which may result in weight loss, further compromising the nutritional and medical status. Findings: During an observation of the lunch meal service on 4/1/25 at 12:15 PM, [NAME] 1 was making grilled cheese sandwich on white bread on the stove. There were two slices of orange cheese and white bread with butter. The grilled cheese sandwich was for Resident 9. A concurrent observation of Resident 9's meal tray showed the grilled cheese sandwich, diet cranberry juice, two Italian ice with no sugar added. Review of Resident 9's meal ticket showed grilled cheese sandwich and a consistent carbohydrate diet (a diet providing the same amount of carbohydrates at each meal and snack to help manage blood sugar levels, especially for individuals with diabetes). During an interview with [NAME] 1 on 4/1/25 at 12:20 PM, she stated she used two slices of cheese to make the grilled cheese sandwich. During an observation of the lunch meal service on 4/2/25 at 11:34 AM, [NAME] 2 was preparing grilled cheese sandwiches on the stove with two slices of white bread and two slices of orange cheese. The grilled cheese sandwich was observing being placed on the meal tray for Resident 62 at that time. During a review of Resident 62's meal ticket showed the resident was on a regular chopped meats diet (a modified diet where foods, including meats, are prepared to be easily chewed and swallowed, often chopped or round into smaller, manageable pieces, typically about ½ inch or smaller). During an interview with [NAME] 2 on 4/2/25 at 11:36 AM, she stated she used two slices of orange cheese to make the grilled cheese sandwich. During an observation at 4/2/25 at 11:40 AM, [NAME] 2 was preparing a grilled cheese sandwich on the stove with two slices of white bread and two slices of orange cheese. The grilled cheese sandwich on white was placed on Resident 5's meal tray with a bowl of tomato soup. During a review of Resident 5's meal ticket showed the resident was on regular diet. During a review of the nutrition label on the package of American cheese, showed that two slices of cheese provided five (5) grams of protein. During a review of the nutrition facts of the regular cut French split loaf, showed the serving size was one-ounce (one slice) for two (2) grams of protein. During a review of the facility menu, showed for the lunch meal contains three ounces of meat (protein). One ounce of protein provides seven (7) grams of protein so three ounces provides 21 grams of protein. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 2 of 5 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 04/08/2025 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the grilled cheese sandwich recipe, showed two slices of bread, two slices of cheddar cheese and two each margarine. During an interview with the Kitchen Manager (KM) on 4/2/2025 at 3:26 PM she confirmed that each grilled cheese sandwich contained approximately nine (9) grams of protein for the 5 grams from two slices of cheese and four (4) grams of protein from two slices of white bread. KM acknowledged that the protein in the grilled cheese alternate meal choice was much lower in protein than the regular entrée which is three ounces of meat. Event ID: Facility ID: 555236 If continuation sheet Page 3 of 5 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 04/08/2025 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 and ice were stored in accordance with professional standards for food service safety when: Residents Affected - Many 1. The ice machine located in the kitchen had a brown substance on the grate above the water trough where water was present; and 2. Food items were above 41 degrees Fahrenheit (F) in three of the four wings (Wing 100, 300, 400) unit refrigerators located on the nursing units. These failures have the potential to result in a growth of microorganisms which can increase the risk of foodborne illness for all the residents eating and drinking at the facility. The facility census was 89. Findings: 1. During an observation of the ice machine located in the kitchen in the presence of the Maintenance Facility Engineer (MFE) on 4/3/2025 at 11:35 AM a brown substance was present on the interior grate located above the water trough inside the ice machine. A concurrent interview was conducted at this time, MFE confirmed the presence of a brown substance in the interior grate above the water trough of the kitchen ice machine and stated that he was able to remove it, indicating a need for more effective cleaning and maintenance. During an observation in the hallway of the facility on 4/3/2025 at 11:53 AM, there was a large drink dispenser with lemonade and ice. During an interview with the Kitchen Manager (KM) on 4/3/25 at 11:59 AM, KM stated the ice from the kitchen's ice machine is used for events, cold drinks on the tray line, and the hallway lemonade dispenser. KM confirmed the lemonade in the hallway is provided as a hydration option for residents. During an interview with the Director of Plant Operations (DPO) on 4/3/25 at 12:56 PM, DPO stated the ice machine is cleaned by contractor quarterly and annually. He stated they just ended the contract with the current vendor and would be starting a new contract through the corporate vendor soon. Review of the work order for the ice machine with a description of Semi-Annual Ice Machine date assigned 1/2/25, showed employee hours entry dated 1/16/25, Food service ice machine cuber for five and a half hours and descaled bin, auger, reservoir and all other surfaces and filled with sanitizing solution then rinsed and drained. Review of the manufacturer's directions of the ice machine, undated, indicated the ice maker must be cleaned and sanitized at least once per year and more frequent cleaning and sanitizing may be required in some water conditions. 2. During an observation of the unit refrigerator on wing 100 on 4/3/25 at 3:04 PM, temperature gauge located inside the refrigerator was 50 degrees F. Low fat milk was 46.4 degrees F, reduced fat milk was 44 degrees F. A concurrent observation and interview were conducted at this time with LN 1, she confirmed thermometer readings of the milk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 4 of 5 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 04/08/2025 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 an observation of the unit refrigerator on wing 300 on 4/3/2025 at 3:10 PM, The gauge located inside the Refrigerator showed 44 degrees F. Reduced fat milk was 44.1degrees F. A concurrent observation and interview were conducted at this time with CNA 1, she confirmed thermometer readings of milk. During an observation of the unit refrigerator on wing 400 on 4/3/2025 at 3:12 PM, the thermometer gauge located inside the refrigerator showed 42 degrees F, a carton of reduced fat milk was 45.9 degrees F. A concurrent observation and interview were conducted at this time with LN 2, she confirmed the thermometer reading of the milk. During a review of the temperature log located on the unit refrigerators dated April 2025, showed food temperatures are to be between 34 and 41 degrees F. During a review of the facility's policy and procedure titled, Food and Nutrition Services (FNS): Food Handling, (August 1, 2024), indicated in part, .temperature of food storage areas and cold food vending and monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555236 If continuation sheet Page 5 of 5