Inspection·June 9, 2023

F 0759 the mistake only after administering the medication to the resident. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure (P&P) titled Nursing Care Center Pharmacy Medication Preparation, not dated, chapter 7, the P&P indicated, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule .Medications are administered in accordance with written orders of the prescriber. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 2 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were stored at the right temperature in accordance with federal laws and the facility's policies and procedures. This failure had the potential for medications to lose potency and become ineffective. Findings: During a concurrent observation and interview, on 6/6/23, at 12:52 p.m., with the Director of Nursing (DON) and the Chief Nursing Officer (CNO), the medication refrigerator temperature was checked and noted to have the temperature read at 28 degrees Fahrenheit. The DON and CNO verified the temperature. The DON verbalized, the medication refrigerator was too cold and outside of temperature parameters. The CNO stated, It's too cold. Things will freeze. Insulin will crystalize below thirty-two degrees and no longer be effective. During a review of the facility's policy and procedures (P&P), titled, Nursing Care Center Pharmacy Storage of Medication, not dated, chapter 4, the P&P indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .Medications requiring refrigeration or temperatures between 2°C (36°F) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring .A daily recorded temperature should be documented and signed off. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 3 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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 - Few 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 Registered Dietitian failed to demonstrate competency when the RD did not communicate current standards of practice to the facility's Medical Director, when the RD was aware a Low Concentrated Sweets (LCS) diet used at the facility was no longer nationally recognized, nor recommended to address residents diabetes. There were two of 12 sampled residents (Resident 48 and Resident 37) with an LCS diet order for nutrition care for diabetes. As a result, the RDs failed to utilize their expertise in the development of resident care policies and procedures to ensure that the facility provides care and services in accordance with current standards of practice, that address resident's diabetes diagnosis, and that provide clinical and technical direction to meet the needs of residents with a diagnosis of diabetes. Findings: During a concurrent observation and interview on 06/06/23, at 11:55 a.m., with Registered Dietitian (RD), in the kitchen, dietary staff were observed using a therapeutic menu/spreadsheet during the lunch trayline (a system of food preparation in which trays move along an assembly line). RD stated the therapeutic menu/spreadsheet that listed LCS meant low concentrated sweets diet and verified the doctors write diet orders for LCS for residents with diabetes in the medical record. RD stated, the LCS diet is incorporated into the facility's diet manual. RD stated, she was aware that LCS diet, along with NCS (No concentrated sweets) and/or RCS (Restricted concentrated sweets) diet was obsolete (out of date) and no longer recognized by the American Academy of Nutrition & Dietetics Nutrition Care Manual, and no longer recognized by the American Diabetes Association as an appropriate diet to treat people with diabetes. The RD stated, she does attend the facility-wide quality assurance meetings and stated she had not discussed that LCS diet used at the facility for care of residents with diabetes was an obsolete diet. RD stated, CCHO (Consistent Carbohydrate) diet was the current standards of practice recommended for nutrition care for people with diabetes. During a concurrent interview and record review on 06/06/23 at 12:20 p.m., with Corporate Registered Dietitian (CRD), in the kitchen, CRD reviewed the therapeutic menu/spreadsheet and verified LCS diet was used at the facility for nutrition care for residents with diabetes. CRD verified the facility's diet manual, menus/menu nutrient analysis and physician orders for care of those with diabetes utilize LCS diet. CRD stated, she was aware the LCS diet was no longer nationally recognized as an appropriate diet for care of persons with diabetes by the American Academy of Nutrition & Dietetics Nutrition Care Manual, and by the American Diabetes Association. CRD verified the Consistent Carbohydrate Diet (CCHO) was the current standards of practice for nutrition care for residents with diabetes. CRD verified the facility LCS diet was not a CCHO diet. CRD stated, We would need to change the diet corporate wide. CRD repeated that she was aware the LCS diet was obsolete and no longer a nationally recognized diet order for those with diabetes. During a review of the facility's Resident Listing Report, provided by the RD, the list included Resident 48, and Resident 37 were residing at the facility with a LCS diet order for diabetes. During a review of Resident 48's Comprehensive Nutrition Assessment (NA), dated 5/19/2023, the NA indicated, .RD obtained preferences and discussed new dx [diagnosis] of DM [diabetes mellitus] .current diet is regular [regular texture] lcs [low concentrated sweets] which appears appropriate at this time ., Taking Metformin [a medication used to treat high blood sugar levels] for DM. She would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 4 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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 like to control it with diet 'as much as possible' . Level of Harm - Minimal harm or potential for actual harm During a review of Resident 37's Face Sheet, dated 6/7/2023, Resident 37's diagnosis included, Type 2 diabetes mellitus . Residents Affected - Few During a review of Resident 37's June 2023 Physician Order Sheet (PO), the PO indicated, Low Concentrated Sweets ., Order Date: 5/30/2023. During an interview on 06/07/23, at 09:46 a.m., with Medical Director (MD), MD stated, he was unaware the LCS diet was an obsolete diet per the American Academy of Nutrition & Dietetics as he relied on the Registered Dietitian's input and expertise related to the system for diet orders. The MD acknowledged he had not heard about the CCHO diet, and that LCS was no longer nationally recognized and stated he was interested in learning more from communication with the facility RD. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2022, the P&P indicated, Policy: The food service department will provide food of the quality and quantity to meet the nutritional needs of individuals. In accordance with the established national standards through nourishing, well-balanced diets, unless contraindicated by medical needs. Based on a facility's reasonable efforts, menus will reflect the needs of the population served. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Manual, dated as last approved on 3/14/2023, the P&P indicated, Policy: The therapeutic diet manual used in the facility will reflect current, evidence-based nutrition knowledge when available, and best practice recommendations where evidence is not available. The manual shall be available for use by the medical staff. It will be reviewed annually by the Continuous Quality Improvement (CQI) committee, including the facility medical director or designee, and revised at least every five years. Procedure: 1. The corporate registered dietitian nutritionist (RDN) will review available diet manual, select, and make recommendations for approval by the medical staff. The medical director or designee will approve the manual, along with the facility RDN, administrator, and director of nursing (DON). 2. The selected therapeutic diet manual will: a. Reflect current nutritional knowledge based on evidence-based research and/or best practice standards. B. Meet established national standards .E. Include information on the role of medical nutrition therapy (MNT) in treating various diseases and conditions. F. Provide clear guidelines for implementing diet orders . The facility's approval page for the Diet Manual, dated 3/14/2023, included the signatures of the Medical Director, and the RD. During a review of the facility's Diet Manual for Low Concentrated Sweets (LCS) Diet, last approved by the facility on 3/14/2023, LCS diet indicated, The Low Concentrated Sweets (LCS) diet is a liberalized diet for adults with abnormal blood glucose metabolism. This diet is similar to the regular diet modified to reduce total sugar intake. The LCS diet is not a calorie controlled or consistent carbohydrate meal plan and is not recognized as a valid diet for treatment of diabetes by the American Diabetes Association. Purpose: To provide a liberalized sugar restricted diet for the control of blood sugar. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2023, the NCM indicated, Obsolete diets and Diet Terminology; For condition Type 1 Diabetes and Type 2 Diabetes Obsolete Diet Name.No Concentrated Sweets diet, No Sugar Added, Low Sugar, Liberal Diabetic Diet. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 5 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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 - Few dated 2023, the NCM indicated, A consistent carbohydrate diet provides the same amount of total carbohydrate daily, distributed evenly across all meals and snacks. A consistent amount of carbohydrate at each daily meal is the goal. The exact amount and type of carbohydrate served is individualized by the registered dietitian nutritionist (RDN). The name of the diet used in your facility should no longer emphasize the restriction of sugar or sweets but rather emphasize consistent carbohydrates or carbohydrate controlled . During a review of Management of Diabetes in Longterm Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association, dated February 2016, the article indicated, No concentrated sweets or no sugar diet orders are ineffective for glycemic [A measure of the increase in the level of blood glucose (a type of sugar) caused by eating a specific carbohydrate (food that contains sugar) compared with eating a standard amount of glucose] management and should not be recommended. Instead, a consistent carbohydrate meal plan that allows for a wide variety of food choices (e.g., general diet) may be more beneficial for both nutritional needs and glycemic control in patients with type 1 diabetes or type 2 diabetes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 6 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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. Based on observation, interview and record review, the facility failed to follow the menu as planned, during lunch trayline (a system of food preparation in which trays move along an assembly line) when: Residents Affected - Few 1. The small portion diet was not followed per the planned menu for one of 12 sampled residents (Resident 10). 2. The SB 6 (Soft, Bite Sized Food) diet was not followed related to the size of pork carnitas in accordance with the facility's planned menu, and Diet Manual for SB 6 diet, for one of 12 sampled residents (Resident 25). This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, not following the correct size of meat for a SB 6 diet had the potential to place the resident at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 06/06/23, at 12:04 p.m., with [NAME] 1, in the kitchen, [NAME] 1 was observed to use a two (2)-ounce (oz.) ladle to serve pork carnitas (diced pork per the recipe) onto Resident 10's lunch meal plate. The 2-oz. ladle was in the pan of pork carnitas on the steam table. [NAME] 1 pointed to the handle of the ladle that indicated 2 oz. and verified it was used for the small portion diet orders. During an observation and interview on 06/06/23, at 12:07 p.m., with Dietary Manager (DM), DM verified with [NAME] 1 that she used a 2-oz. ladle to serve pork carnitas onto Resident 10's lunch plate. DM verified an incorrect portion was served, and DM stated, a # (number)10 scoop should have been used to serve Resident 10 pork carnitas as indicated on the planned menu for the small portion diet. DM pointed to a poster located on the wall near the trayline area that indicated, Scoop Sizes .#10 (3 ¼ [quarter] oz.) . DM verified the expectation was for the cook to follow the portion sizes per the planned menu/therapeutic spreadsheet. During a review of Resident 10's meal tray ticket (MTT), the MTT indicated, Small Prtn [Small Portion] .Pork Carnitas (#10 scoop) . During a review of the therapeutic menu spreadsheet, the small prtn diet indicated a #10 scoop should be used for the pork carnitas. Directions located at the bottom of the therapeutic menu spreadsheet indicated, No. [number] 10 scoop: 3-4 oz. During a review of Resident 10's Comprehensive Nutrition Assessment (NA), dated 06/02/2023, the NA indicated, Diet is regular with small portions, per resident request. During a review of Resident 10's June 2023 Physician Order Sheet (PO), the PO indicated, Regular, Small Portions .Per resident request ., Order Date: 9/29/2021. During a review of the facility's policy and procedure (P&P) titled, Portion Control, dated 2022, the P&P indicated, Policy: Individuals will receive the appropriate portions of food as outlined on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 7 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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 - Few the menu ., Procedure: 2. The menu's spreadsheet should list the specific portion size for each food item. Spreadsheets should be posted at the tray line so staff can refer to the proper portions for each diet ., 3 .Portions that are too small result in the individual not receiving the nutrients needed ., #10 scoop .ounce amount 3 ¼ ounces . 2. During a concurrent observation and interview on 06/06/23, at 12:12 p.m., with [NAME] 1, in the kitchen, Dietary Aide (DA) 2 called out Resident 25's diet order for SB 6 to the cook (Cook 1). [NAME] 1 was observed plating Resident 25's lunch meal plate. DA 2 was observed placing Resident 25's lunch plate onto the meal tray located in the meal delivery cart. DA 2 was asked to remove Resident 25's lunch plate, and DA 2 verified Resident 25's lunch plate with SB 6 diet order. Concurrently, Dietary Manager (DM) was asked to review Resident 25's lunch meal plate for accuracy. DM reviewed Resident 25's lunch meal plate and informed the cook that the pork carnitas pieces of meat needed to be smaller for SB 6 diet order. During a concurrent observation and interview on 06/06/23, at 12:15 p.m., with Registered Dietitian (RD) and DM, in the kitchen, RD observed the large pan of pork carnitas located in the steamtable and stated there were pieces of pork that were larger than ½ (half inch) in size that would not be allowed on a SB 6 diet. DM stated, the same serving pan of pork carnitas was used that held smaller pieces of pork that were ½ or smaller for SB 6 diets, as well as regular sized pieces of pork carnitas. DM stated [NAME] 1 was trained to serve the smaller sized pieces of pork carnitas that were located more in the center lower edge of the pan. DM acknowledged that there were larger pieces of pork that could easily be comingled or hidden underneath a layer of other pieces of meat. DM stated that a different cook would have put the pieces of pork carnitas that were ½ (inch) or smaller in its own pan, separate from the regular sized pieces of pork carnitas for the regular diets to ensure the SB 6 would have been served appropriately on a consistent basis. During a review of the recipe for Pork Carnitas (IDDSI [International Dysphagia [difficulty in swallowing] Diet Standardisation]), the recipe included directions that indicated, IDDSI Level 6- Soft & Bite Sized: Chop/cut food into pieces = 15mm (millimeters- a unit of measurement) by 15 mm in size . During a review of Resident 25's meal tray ticket (MTT), the MTT indicated, SB6 .Pork Carnitas . During a review of Resident 25's June 2023 Physician Order Sheet (PO), the PO indicated, Diet: Soft & Bite-Size-IDDSI Level 6 (Mech [mechanical] Soft, Chopped Meat) ., Order Date: 3/27/2023. During a review of Resident 25's Speech Therapy SLP [speech-language pathologist] Evaluation and Plan of Treatment, dated 3/24/ 2023, the SLP Plan of Treatment indicated, Without therapy pt [patient] at risk for .reduced PO [food eaten by mouth] safety and aspiration [food or liquid goes into the airway instead of the stomach] ., Recommended for the patient to swallow solids safely = Soft & bite sized. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Manual, dated as last approved on 3/14/2023, the P&P indicated, Policy: The therapeutic diet manual used in the facility will reflect current, evidence-based nutrition knowledge when available ., Be representative of the diets appropriate for and/or needed by the residents served . During a review of the facility's Diet Manual for the IDDSI Level 6 - Soft, Bite Sized Food (SB 6) diet, last approved by the facility on 3/14/2023, SB 6 diet indicated, This diet is used in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555554 If continuation sheet Page 8 of 9 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 555554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coastal Oaks Special Care Center 10805 El Camino Real Atascadero, CA 93422 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dietary management of dysphagia with food texture modification described as soft, tender, moist food with no separate think liquids. Foods should have a particle size no greater than 15 mm length by 15 mm width for adults . (15 mm by 15 mm is equivalent to 1.5 cm [centimeter] by 1.5 cm https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/6_Soft_Bite_Sized_Adult_consumer_handout_30Jan2019.p 1.5 cm is equivalent to 0.59 (or ½ inch) https://grinebiter.com/centimeter/where-is-1.5-cm-on-a-ruler.html). Event ID: Facility ID: 555554 If continuation sheet Page 9 of 9