Health inspection·February 10, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of 19 sampled residents (Resident 53), received reasonable accommodation on the use of a call bell. Residents Affected - Few This failure had the potential to not meet the health care needs of the Resident 53. Findings: During a review of Resident 53's MDS (Minimum Data Set - a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) 3.0 Nursing Home Quarterly Assessment . Section C - Cognitive Patterns . BIMS (Brief Interview for Mental Status) Summary Score, dated 1/12/23, Resident 53's BIMS indicated, a score of 11. During a concurrent observation and interview, on 2/6/23 at 10:45 a.m., with Resident 53, Resident 53 was observed in bed, awake, alert, and verbally consented to an interview. A visual inspection of Resident 53's room revealed, a call light system wall receptacle was installed, but the actual call light device cord was missing. A metal, desk call bell was noted on top of the Resident 53's left bedside table. When asked how Resident 53 would alert the staff if Resident 53 needed help or assistance, Resident 53 stated, Resident 53 would yell, Help, help! Resident 53 was reminded there was a call bell on the bedside table. To demonstrate how accessible the call bell was for Resident 53, Resident 53 was asked to reach for it while in bed, but Resident 53 could not do it. During a concurrent observation and interview, on 2/8/23 at 2:57 p.m., with a licensed nurse (LN 1), inside Resident 53's room, Resident 53's living set up was observed. Resident 53's call bell was noted in the same location, on top of the left bedside table, far from the resident's reach. Resident 53 could not reach the call bell while in bed when requested to use it. LN 1 confirmed and acknowledged, the call bell was not accessible to Resident 53. LN 1 mentioned, staff conducted their rounds frequently to check on Resident 53, but could not specify the exact times, nor was able to provide documentation of those rounds. During a review of Resident 53's, Care Plan Report, undated, the Care Plan Report indicated, (Resident 53) does not use the call light for assistance. The call light is a hazard for the resident due to possible tripping or getting wrapped around it. Further review of the Care Plan Report indicated, the intervention, Place call bell accessible to the resident. The intervention was not followed as observed inside Resident 53's room. During a review of the facility's policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated in part, Policy Interpretation and Implementation . 9) Areas of concern that are identified during the resident assessment will be evaluated before Page 1 of 25 555762 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0558 Level of Harm - Minimal harm or potential for actual harm interventions are added to the care plan, 10) Identifying the problem areas and their causes, developing interventions that are targeted and meaningful to the resident The P&P also indicated, 11) Care interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making. Residents Affected - Few 555762 Page 2 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation and interview, the facility failed to ensure a list of the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman was posted in at least four specific locations, that are frequently visited and readily accessible to the residents. This failure had the potential for residents to not know how to contact the Ombudsman, to address their concerns. Findings: During the initial tour of the facility on 2/6/23, at 10:50 a.m., the Ombudsman's contact information was not posted in the facility's dining and activity rooms, that are frequently visited by the residents. There was only one poster with the Ombudsman's information located in the facility. During an observation on 2/6/23, at 11:30 a.m., with the Director of Nursing (DON), the DON acknowledged, there was only one Ombudsman poster in the facility. During a follow up interview with the DON on 2/9/23, at 11:16 a.m., the DON further acknowledged, the Ombudsman's information was not posted in a location frequently visited and accessible to the residents. 555762 Page 3 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the binder, containing the results of the previous survey, was readily accessible to view by residents, resident's representatives, and/or other individuals. Residents Affected - Few This failure had the potential to deny individuals, including residents and representatives', access to the facility's history of survey results. Findings: During a concurrent observation and interview, on 2/6/23, at 11:15 a.m., with the Medical Records Director (MRD - an individual that oversees resident's health record in healthcare facilities), the MRD was unable to locate the binder containing the previous survey results. During an interview on 2/6/23, at 11:20 a.m., with the Certified Nursing Assistant Scheduler (CNA Scheduler - an employee responsible for CNA daily working schedule), the CNA Scheduler acknowledged, the binder was in the Administrator's office, and was not in the reception area, at the front lobby, where the binder was supposed to be. During an interview on 2/9/23, at 11:16 a.m., with the Director of Nursing (DON), the DON, verbalized, the binder must be at the reception area at all the times, accessible for the residents and the family members to read. 555762 Page 4 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC), at least two days before the end of a Medicare covered Part A stay, or when all of Part B therapies were ending for one of three sampled residents (Resident 29). Residents Affected - Few This failure resulted in Resident 29 not afforded the opportunity for an appeal. Findings: During a concurrent interview and record review, on 2/8/23 at 3:09 p.m., with the Director of Nursing (DON), Resident 29's NOMNOC form, dated 2/17/22 was reviewed. The NOMNC indicated, Resident 29 had signed the form on 12/17/22, the day after coverage ended on 12/16/22. The DON concurred, the date (12/17/22) on the NOMNOC, was after the services were discontinued on 12/16/22. 555762 Page 5 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0622 Level of Harm - Minimal harm or potential for actual harm Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on record review and interview, the facility failed to provide appropriate documentation for one of four sampled residents' (Resident 23) clinical record, dated 2/2, when Resident 23: Residents Affected - Few 1. Had no documentation when Resident 23 went for an appointment with the wound specialist and returned back to the facility. 2. Had no documentation of Resident 23's overall condition when Resident 23 was taken to the hospital, by Resident 23's family representative, for gastrostomy tube placement (a procedure for placement of feeding tube through the stomach). This failure had the potential for Resident 23 to be at increased risk for complications, and adverse outcomes. Findings: 1. During a review of Resident 23's After Visit Summary, dated 2/2/23, at 10:45 a.m., the After Visit Summary indicated, Resident 23's stage 3 pressure ulcer (a bedsore that was deep involving skin loss throughout the thickness of the skin) was addressed and Resident 23 is to come back for follow up visit on 2/9/23, at 2:45 p.m. During an interview on 2/8/23, at 4:00 p.m., with the Minimum Data Set Coordinator (MDSC - a person responsible for collecting data for assessments in a nursing home), the MDSC verbalized, Resident 23 went for a wound specialist appointment on 2/2, and there was no documentation if Resident 23 returned and came back to the facility. 2. During a concurrent record review and interview on 2/8/23, at 3:26 p.m., with the MDSC, the Minimum Data Set Discharge Assessment (MDSDA - an assessment collected when a resident is discharged from a facility) was reviewed. The MDSDA indicated, Resident 23 was discharge and expected to return to the facility. The MDSC verified, Resident 23 was discharged on 2/2, and had not returned back to the facility. During a review of Resident's 23's Resident Notes Report, dated 2/2023, the Resident Notes Report indicated, Resident 23 was taken to the hospital by Resident 23's representative to be assessed for gastrostomy tube placement. During an interview on 2/9/23, at 10:10 a.m., with the Licensed Vocational Nurse (LN 6), LN 6 acknowledged, not documenting, and should have documented Resident 23's overall condition on the clinical record when Resident 23 was taken to the hospital. During an interview on 2/9/23, at 11:16 a.m., with the Director of Nursing (DON), the DON acknowledged and verbalized, there was no documentation when Resident 23 was seen by the wound specialist and no documentation of the overall condition when Resident 23 was discharge on 2/2. The DON further verbalized, there must be a documentation on the resident's clinical record. During a review of the facility's policy and procedure (P&P) titled, Admission, Discharge, and Transfer of Care, dated 11/2016, the P&P indicated, 5. Recommend use of discharge/transfer form .with 555762 Page 6 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few final documentation in the resident medical record. Specify the following .Facility must provide and document orientation regarding transfer or discharge to ensure a safe transition to the extent possible. During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated, Documentation in the medical record will be objective .complete, and accurate. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure; e. whether the resident refused the procedure/treatment; f. notification of family, physician, or other staff .and g. the signature and title of the individual documenting. 555762 Page 7 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) were transmitted timely, per regulation for four of eight residents sampled (Residents 57, 28, 9, and 54). Residents Affected - Some This failure resulted in the facility's non-compliance with the regulatory requirements; and had the potential for not knowing resident's whereabouts and current conditions. Findings: During a review of the facility's provided CMS RAI (Resident Assessment Instrument) 3.0 Manual, dated October 2019, the manual indicated, .The Quarterly assessment must be transmitted no later than 14 later than 14 calendar days after the Entry and discharge date . During a concurrent record review and observation on 2/9/23, at 11:30 a.m., with the MDS coordinator (MDSC), the facility's MDS transmittal records (multiple dates) was reviewed. The records indicated: -Resident 57's quarterly assessment, with reference date of 12/29/22, remained open with no completion date. Resident 57 was discharged on 1/6/23, and the MDS assessment was completed on 1/6/23. -Resident 28's quarterly assessment, with reference date of 12/27/22, remained open without a completion date. -Resident 9's quarterly assessment, with reference date of 12/14/22, was completed on 1/9/23. -Resident 54 was discharged on 9/25/22, and the MDS assessment was completed on 9/25/22. On 2/9/23 all five assessments were found not transmitted to the federal database, and the 14 days requirement for submission was unmet. During an interview with the MDSC on 2/9/23, at 2:50 p.m., the MDSC acknowledged, the MDS transmittals for Residents 57, 28, 9, and 54 were not transmitted as stipulated in the regulation. 555762 Page 8 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to ensure the care plan for one of 19 sampled residents (Residents 53) was followed, and evaluated, to reflect the residents' current health needs were met when Resident 53's call bell was not accessible for use. This failure had the potential not to meet the health care needs of the Resident 53. Findings: 1) During a review of Resident 53's, MDS (Minimum Data Set - a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) 3.0 Nursing Home Quarterly Assessment .Section C - Cognitive Patterns .BIMS (Brief Interview for Mental Status) Summary Score, dated 1/12/23, Resident 53's BIMS indicated, a score of 11. During a concurrent observation and interview, on 2/6/23, at 10:45 a.m., with Resident 53, the resident was observed in bed, awake, alert, and verbally consented for an interview. A visual inspection of Resident 53's room revealed, a call light system wall receptacle was installed, but the actual call light device cord was missing. A metal, desk call bell was noted on top of the Resident 53's left bedside table. When asked how the resident would alert the staff if he needed help or assistance, Resident 53 stated, Resident 53 would yell, Help, help! Resident 53 was reminded there was a call bell on the bedside table. To demonstrate how accessible the call bell was for Resident 53, the resident was asked to reach for it while in bed, but Resident 53 could not do it. During a concurrent observation and interview, on 2/8/23, at 2:57 p.m., with a licensed nurse (LN 1), inside Resident 53's room, Resident 53's room layout was observed. Resident 53's call bell was noted in the same location, on top of the left bedside table, far from the resident's reach. Resident 53 could not reach the call bell while in bed, when requested to use it. LN 1 confirmed and acknowledged, the call bell was not accessible to the resident. LN 1 mentioned, staff conducted their rounds frequently to check on Resident 53, but could not specify the exact times, nor was able to provide documentation of those rounds. During a review of Resident 53's, Care Plan Report, undated, a care plan indicated, (Resident 53) does not use the call light for assistance. The call light is a hazard for the resident due to possible tripping or getting wrapped around it. Further review of the care plan indicated, the intervention, Place call bell accessible to the resident. The intervention was not followed as observed inside Resident 53's room. During a review of the facility's, policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated in part, Policy Interpretation and Implementation . 9) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan, 10) Identifying the problem areas and their causes, developing interventions that are targeted and meaningful to the resident The P&P also indicated, 11) Care interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making. 555762 Page 9 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, inspection, and interview, the facility failed to meet residents' needs with pharmaceutical services and medications when: 1. Expired and unusable drugs/medications were available for resident administration. 2. One of three residents (Resident 322) received a higher dose of psychotropic medication than agreed to on the Facility Verification/Informed Consent for Psychotherapeutic Medications. These failures had the potential to cause a decline in residents' health from receiving ineffective/expired and/or overdose of medications which may have been unsafe, improper, and unapproved for medication administration. Findings: 1. Inspection of the facility's Treasure Medication room and the Garden Medication room nursing stations on [DATE] between 9:50 am and 3:23 pm, revealed the following expired/unuseable medications: One bottle of Debrox (ear cleaning solution) had been unopened but this bottle had a manufacturer's expiration date of [DATE]. Two open bottles of PPD (Purified Protien Derivative), which are used for Tuberculosis testing, the drug manufacturer (on the outside of the bottle), indicates that this product must be discarded 30 days after opening. One (I.V.) intravenous piggyback antibiotic (Ceftriaxone, also know as Rocephin) in 100 milliliters of Sodium Chloride solution had been stored in the facility's medication refrigerator with an expiration date of [DATE]. One bottle of Amoxicillin Clavulanate Potsssium (an antibiotic) oral suspension 250 milligrams in 150 milliliters, which had been mixed by the facility's Pharmacy on [DATE]. The Pharmacy had written a expiration date of 7/2024 on the outside of this bottle, but on the outside of this bottle the drugs manufacturer's label read: discard after 10 days. Multiple packets of Triple antibiotic Onitment with an expiration date of 1/2023 were found inside the facility's medication treatment cart. 2. According to the facility policy and procedure titled, Use of Psychotropic Medications review date 4/2014 indicated in part, Any resident prescribed a psychotropic medication will receive an assessment and evaluation prior to the start of the medication and an appropriate consent will be presented, reviewed, and signed by the consenting parties . When medication is prescribed, residents will only receive the medications in the dose and for the duration clinically indicated to treat the resident's assessed condition . During a concurrent record review and interview with the director of nursing (DON) on [DATE] at 12:59 p.m. Resident 322's clinical records were reviewed. The Facility Verification/Informed Consent for Psychotherapeutic Medications (informed consent form) signed by Resident 322's representative, a facility witness, and the Physician, indicated 10 milligrams of Sertraline (a drug that helps treat depression) be given by mouth once a day, for depression. The Physician Order Sheet indicated Sertraline 100 mg tablet, oral (by mouth), one time daily, starting on [DATE]. Also, the January and February 2023 Medications (medication administration record) indicated Resident 322 received 100 mg Sertraline once a day from [DATE] through [DATE] instead of the 10 mg indicated and agreed upon on the informed consent form. Additionally reviewed the facility policy and procedure Use of Psychotropic Medications. When asked if giving 100 mg of Sertraline instead of the consented 10 mg of Sertraline to 555762 Page 10 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0755 Resident 322 was appropriate and if the facility policy and procedure for psychotropic medication use was followed/implemented, the DON acknowledged, No. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555762 Page 11 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure psychotropic medication orders were written with appropriate indications for two sampled residents (Res 36 and 39). 1. Quetiapine (Seroquel) (medication to treat Schizophrenia (mental disorder causing a person to become disconnected with reality) was ordered for Res 39 with a diagnosis of Dementia. 2. Resident 36 was prescribed Trazodone (a medication used to treat depression), for the inability to fall asleep. This failure resulted in Resident 39 and Resident 36 receiving an unnecessary medication. Findings: 1. During a review of Res 39's Physician Order Sheet, dated February 2023, the Physician Order Sheet indicated in part, .Quetiapine 100 milligram tablet Dx (diagnosis): Dementia with behavioral disturbances M/B (manifested by) yelling/screaming during care . Quetiapine 25 milligram tablet .Dx: Dementia with behavioral disturbances . During a review of the facility's Long Term Care Nursing Drug Handbook PharMerica, page 1436, dated 2017, indicated in part, . [US Boxed Warning]: Elderly patients with dementia-related psychosis treated with anti-psychotics are at an increased risk of death During an interview on 02/09/23, at 1:30 p.m., with the Director of Nursing (DON), the DON stated, I'm familiar with the Black Box Warning with antipsychotics with elders with dementia diagnosis. When asked if this was an inappropriate indication, the DON confirmed, that the order for Quetiapine with Dx of Dementia was inappropriate by stating, Yes, based on the Black Box Warning. During a review of Facility Verification/ Informed Consent for Psychotropic Medications, dated 6/20/22 and 7/19/22, both forms indicated in part, .Indication for Use .Dementia with behavioral disturbances . During a review of the facility's policy and procedure titled, Use of Psychotropic Medications, dated 4/03/14, indicated in part, . Policy: It is the policy of .to work with all providers and the interdisciplinary team to ensure a resident's medication regimen is free of unnecessary drugs. This includes the prescription and use of psychotropic medications Purpose: . an appropriate consent will be presented, reviewed, and signed by the consenting parties 2. Resident 36, an [AGE] year-old, was admitted on [DATE], with multiple diagnoses, including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's Order Profile (a list of medications) dated 1/12/23, the Order Profile indicated, an order for trazodone, 50 mg (milligrams) tablet, 1 tab (tablet) Oral. The order indicated, Dx: (diagnosis) insomnia m/b (manifested by) inability to fall asleep, Instructions: 555762 Page 12 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Therapeutic Range: One Time Daily Starting 01/12/2023. Instructions: Therapeutic Range: One Time Daily Starting 01/12/2023. During a review of Resident 36's Facility Verification/Informed Consent for Psychotherapeutic Medication form, dated 1/12/23, the form indicated, Trazodone dose, 50mg, Route, PO, (by mouth) frequency, gHS (give hour of sleep) Indications, insomnia m/b (manifested by) inability to fall asleep. During a review of Resident 36's care plan titled, Risk for falls risk for alteration in sleep patterns, the care plan indicated, .inability to fall asleep. (Resident 36) is on Trazodone for insomnia and Melatonin to help regulate circadian rhythm (a natural, internal process that regulates the sleep-wake cycle and repeats roughly every 24 hours). There were no interventions in place for non-drug therapy to assist with Resident 36's inability to sleep. During an interview on 02/08/23, at 10:31 a.m., with licensed nurse (LN 2), LN 2 was asked if Resident 36 receives the medication trazadone. LN 2 stated, Yes, we give trazadone for sleep. One night (Resident 36) would sleep fine, and the next night (Resident 36) would not sleep at all. During an interview on 02/09/23, at 01:30 p.m., with the Director of Nursing (DON), the DON was asked about the trazadone medication order for Resident 36, with an indication of inability to sleep. The DON stated, There should have been a clarification on the order for correct diagnosis. During a review of the Pragma Pharmaceuticals, LLC (the manufacturer of Trazodone), manufacturer's label, the label indicated, in their product package information, dated 6/2017, (Trazodone) DESYREL is indicated for the treatment of major depressive disorder (MDD) (1). DOSAGE AND ADMINISTRATION, Starting dose: 150 mg IN Divided DOSES DAILY. May be increased by 50 mg per day every three to four days. Maximum dose: 400 mg per day in divided doses (2.1) . As indicated in the manufacturer's product information, this medication should be administered in Divided daily dosages, not just once a day at BEDTIME. 555762 Page 13 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 Director of Food and Nutrition Services (Dietary Manager) met the state's education qualification requirements, as required per federal regulation, to be the Dietary Manager to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the full-time Clinical Dietitian provided frequently scheduled consultation to the Dietary Manager to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with safe food handling and sanitation (Cross Reference F812), meal distribution accuracy (Cross Reference F803, F805) and puree meal preparation (Cross Reference F804), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day to day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of the expertise of RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DM by the RD, when the RD was the full-time Clinical Dietitian. There was a total of 53 residents receiving meals from the main kitchen and main dining room. Findings: During a concurrent observation and interview on 02/06/23, at 9:45 a.m., with Lead [NAME] (LC), in the walk-in refrigerator in the main kitchen, LC observed a large pan of cooked pasta labeled as 2-6-23 9:45 a.m. LC stated, he cooked the pasta that morning and it was for macaroni and cheese for the residents lunch today. During a concurrent observation and interview on 02/06/23, at 10:02 AM, with Registered Dietitian (RD), in the main kitchen, a scoop was observed touching uncooked rice inside a dry storage ingredient bin. The RD verified the scoop should not have been stored touching the rice as it was a source for potential cross contamination. The RD was asked where the dietary staff were supposed to store the scoop, and RD stated, she did not know but the Dietary Manager (DM) would know. The DM was not available on 2/6/23 to interview. During a concurrent observation and interview on 02/06/23, at 10:03 a.m., in the presence of the RD, LC was asked for the cool down log. LC stated, We don't have a cool down log. Concurrently, the RD verified pasta is a TCS food, and RD stated, she did not know if the staff had a cool down log. The RD stated the DM would know as she was the clinical Dietitian. During an interview on 02/06/23, at 12:35 p.m., with RD, RD stated, she wasn't aware what portion sizes were planned today but she can get a copy of the menu extension. RD stated, she was not aware dietary staff serving meals in the dining room did not have the menu extension posted that contained direction on the portion sizes to serve. RD stated, Dietary Manager would know. The RD stated she was the clinical Dietitian. The DM was not available on 2/6/23 to interview. During a concurrent observation and interview on 02/06/23, at 12:39 p.m., with RD, in the main dining room, the RD compared the portion sizes being served by DA 1 for the regular diet to the menu extension. The RD stated 2 oz. of mac & cheese was served and it should have been 4 oz. The RD stated 2 555762 Page 14 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many oz. of soup was served and it should have been 8 oz The RD stated, DA 1 was not serving 4 oz. of broccoli and should have used a measured scoop to ensure 4 oz. of broccoli was served. During an interview on 02/08/23, at 10:37 a.m., with DM, DM stated he was responsible for running the day-to-day food service operations for the skilled nursing facility. The DM stated he was not a Certified Dietary Manager and his credentials are ServSafe, and restaurant experience. During an interview on 02/08/23, at 10:45 a.m., with DM, in the presence of the Administrator (Admin), the DM reviewed the state's qualifying pathways that meet a DM's state education qualifications as listed in the Health and Safety Code 1265.4 (H & SC 1265.4). DM stated, he had not met any of the qualifying pathways to be a dietary manager (interchangeable with the state's terminology for a dietary services supervisor) as listed in H &SC 1265.4. The following state Title 22 requirement was shared with the DM and Admin; Title 22, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. During an interview on 02/08/23, at 10:45 a.m., with DM, in the presence of the Administrator (Admin), the DM verified that he was in charge of the day to day food service operation for the skilled nursing facility residents. The DM verified the RD was the Clinical Dietitian. The deficiencies that occurred during the survey related to food and nutrition services had not had the benefit of the RD expertise to have an opportunity to assist the facility to self-identify and self- resolve the food safety and food distribution concerns to ensure resident health and safety, as evidenced by interviews with the RD. The RD had not had a sufficient role to provide frequently scheduled consultation to the DM related to safety and sanitation of the food service department. The Admin stated, the DM and RD speak all the time. The Admin was unable to provide written consultation reports by the RD related to food safety, food preparation, food storage or sanitation of the food service operation. The Admin stated, Oh, so you are saying it needs to be in writing?. During an interview on 02/08/23, at 10:50 a.m., with RD, RD stated, she was unaware the facility's Dietary Manager was not a Certified Dietary Manager. The RD stated she works for an outside contract and was contractually hired to be the facility's full time Clinical Dietitian. The RD stated, she does not have a role or any tasks related to overseeing food safety and sanitation to include food preparation, monitoring meal tray line service and food storage. The RD verified the responsibility of the day to day food service operation was the Dietary Manager's position. The RD stated she does not perform any type of food safety and sanitation audits or monitoring over the food service operation. The RD stated her interactions that pertained to the dietary staff were limited to instructing on the diet manual, periodically reviews accuracy of residents meal tray tickets (the paper tickets that include diet orders and resident specific instruction regarding meal service) but does not include overseeing, or monitoring tray line meal service, and she used a form to complete with residents regarding their experience with their meals. RD stated, she had worked at the facility for approximately 2 1/2 years. During a review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), the SOM defined the word Consultants as the following; means an individual who gives professional advice or services. They are generally not direct employees of the facility and may work either full or part-time. During a review of the RD's job description (JD), the JD indicated, Clinical Dietitian; Position Summary: Responsible for providing comprehensive nutrition assessments and care planning for patients 555762 Page 15 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and residents with special needs. Implements business practices in order to uphold Company mission and values. Contributes to account revenues and operating profit contribution through the implementation of services ., Duties: Directs dietary care of patients and residents with special needs including screening, assessment, intervention, care and discharge planning to ensure patient nutrition needs and customer satisfaction levels are met. Educates medical staff and counsels patients/residents and their families on proper nutritional care. Manages and promotes food and nutrition programs according to [name of contracted company] standards and policy. Collaborates and communicates with culinary and clinical departments on established processes, special diets, and menu requests. Stays current with most recent nutrition-related trends, research, policy, certifications, and standards of practice. Probes potential problems and apprises manager of status on resolution of problems or issues using appropriate [name of outside company] resource when necessary. Ensures compliance with all federal, state and local regulations as well as [name of outside company]/client policies and procedures .Establishes operating standards, implements quality improvements and communicates them to other departments. During an interview on 02/08/23, at 12:07 p.m., 6/3/18, with Director of Dining (DOD), the DOD stated, the DM was hired to be the Dietary Manager to run the day to day food service operations for the skilled nursing facility residents. The DOD verified the RD was hired to be the Clinical Dietitian. The DOD described her position as an Administration function dealing with fiscal. The DOD stated she was not involved in the day to day food service operation of the main kitchen for the skilled nursing facility, and stated she had not met any of the educational pathways to be a Dietary Manager as listed in the H & SC 1265.4. During a review of the DOD's job description (JD) titled GM 4, Food, that was provided by the DOD, the JD indicated, Position Summary: Provides local leadership and strategic direction to build client relationships and new business opportunities to enhance profitability for the Company. Directs business practices in order to uphold Company mission and values. Develops new and emerging business solutions for sustained growth and effective day-to-day operations ., Duties: .Supervises day-to-day work activities by delegating authority, assigning and prioritizing activities, and monitoring operating standards ., Creates and manages the budget by increasing revenue and controlling unit expenditures to ensure accuracy of operating and administrative budget ., Directs daily food service operations, including: menu evaluation and planning, purchasing, inventory, receiving, food preparation and storage. Maintains kitchen and storage facilities to meet/exceed sanitary conditions, monitors internal quality assurance and food safety audit process (including HACCP [Hazard Analysis Critical Control Point] record keeping). During a review of the DM's job description (JD) titled Health Care Dietary Manager, the JD indicated, Purpose of Position: This position is responsible for all aspects of supervision and administration of the day to day nutritional care and food service operations for the Skilled Nursing at the [name of the Skilled Nursing Facility] ., reports to Director of Dining Services [DOD]. 555762 Page 16 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu as planned when: 1a. The portion size for the regular diet was not followed during the lunch tray line observation located in the main dining room. 1b. In addition, the portion size for soup was not followed during a lunch tray line observation located in the main kitchen. 2. A therapeutic diet order was not followed per the planned Heart Healthy menu for one of 19 sampled residents (Resident 100). The facility failure to ensure dietary staff followed the menu had the potential to not meet the residents' nutritional needs. There was a total of 53 residents receiving meals from the main kitchen and main dining room. Findings: 1a. During a concurrent observation and interview on 02/06/23, at 12:03 p.m., with Dietary Aide (DA) 1, in the main dining room, DA 1 was observed serving residents the lunch meal from a steam table. DA 1 pointed to the ladle that was located in the soup, and DA 1 stated, she was serving 2 ounces (oz.) of chowder soup for the regular diet orders. DA 1 showed the blue handled scoop she used for the macaroni and cheese (mac & cheese), and DA 1 stated, she was serving 2 oz. of the mac & cheese for the regular diet orders. DA 1 was observed using a slotted spoon to serve the broccoli for the regular diet orders, and DA 1 stated, the slotted spoon had not contained a measurement on the utensil. DA 1 stated she had been employed at the facility for approximately eight months. During a concurrent observation and interview on 02/06/23, at 12:06 p.m., with Director of Dining (DOD), in the main dining room, the DOD stated, DA 1 knew what portion sizes to use by training. DOD observed the portion sizes DA 1 was serving. DOD had not identified a concern with the portion sizes being served by DA 1 on the regular diet orders. During an interview on 02/06/23, at 12:35 p.m., with Registered Dietitian (RD), RD stated, she wasn't aware what portion sizes were planned today but she can get a copy of the menu extension. RD stated, she was not aware dietary staff serving meals in the dining room did not have the menu extension posted that contained direction on the portion sizes to serve. RD stated, Dietary Manager would know. The RD stated she was the clinical Dietitian. The Dietary Manager (DM) was not available on 2/6/23 to interview. During a concurrent observation and interview on 02/06/23, at 12:39 p.m., with RD, in the main dining room, the RD compared the portion sizes being served by DA 1 for the regular diet to the menu extension. The RD stated 2 oz. of mac & cheese was served and it should have been 4 oz. The RD stated 2 oz. of soup was served and it should have been 8 oz The RD stated, DA 1 was not serving 4 oz. of broccoli and should have used a measured scoop to ensure 4 oz. of broccoli was served. During an interview on 02/08/23, at 10:07 a.m., with DM, DM stated, DA 1 should have had the menu extension readily available and should have followed the portion sizes listed on the menu extension. The DM was asked if there was a monitoring, or audit system in place to ensure dietary staff in the 555762 Page 17 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dining room followed the planned portion sizes. The DM stated, he did not know how long it had been that the menu extensions were not posted in the main dining room to be followed. DM stated, approximately 15 20 residents receive their lunch meal from the main dining room. During a review of the menu extension (ME), labeled as Spring Week 1 Monday, the ME indicated, Regular [diet], .Chowder Soup - 8 oz Ladle, Baked Mac & Cheese - 4 oz ladle, Broccoli 4 oz . 1.b During a concurrent observation and interview on 02/07/23, at 1:10 p.m., with Lead [NAME] (LC), in the main kitchen, LC was observed placing chicken noodle soup into a bowl using a ladle located in the soup in the steam table for regular diet orders. LC was observed using one ladle for the soup. LC observed the measurement listed on the ladle, and LC stated, It's 6 ounces (oz.). LC was asked if 6 oz was the correct portion size, and LC checked the menu extension that was posted behind him underneath other papers, and LC stated, 6 oz. was not correct, and he should have used an 8 oz. ladle. During a concurrent observation and interview on 02/07/23, at 1:13 p.m., with Lead [NAME] (LC), in the presence of dietary aide (DA) 2, in the main kitchen, Resident 47's meal tray was located on the meal delivery cart. Resident 47's meal tray ticket indicated fortified diet and to serve fortified soup. LC was asked the quantity of fortified soup that was served to Resident 47, and LC stated, 6 oz. LC verified the incorrect portion of fortified soup was served to Resident 47. During a review of the menu extension (ME), labeled as Spring Week 1 Tuesday, the ME indicated, Regular diet, chicken noodle soup - 8 oz. Ladle ., Fortified diet 8 oz. Fortified soup. During a review of Resident 47's Diet Order (DO), dated 10/18/2022, the DO indicated, Fortified diet and fortified soup for lunch and dinner. During a review of the facility's policy and procedure (P&P) titled, Every Bite Counts (fortified foods), undated, the P & P indicated, Purpose: Creation of an individualized high-calorie, high-protein food intervention for residents at nutritional risk. The Every Bite Counts (EBC program) increases the amount of calories and protein served to residents . During a review of the facility's policy and procedure (P&P) titled, Section 2: Diets & Menus Menu Extensions/Diet Spreadsheets, dated 1/2016, the P & P indicated, Policy: Menu extensions are to be available, referred to, and followed with each meal that is prepared and served. Therapeutic menus will be written for all diets served in the facility. Procedures: 1. Each employee is responsible for following the prepared menu extensions. 2. It is the management team's duty to ensure that the menu extensions are accurate and updated as needed. Management team will provide menu extensions for every serving area. 3. When serving, the employee refers to the menu extensions to ensure that the proper portion sizes and diet needs are being met . 2. During a concurrent observation and interview on 02/07/23, at 1:00 p.m., with dietary aide (DA) 2, in the main kitchen, Resident 100's lunch meal tray was observed on the meal delivery cart. Resident 100's meal tray ticket indicated Heart Healthy diet. A packet of salt was observed on Resident 100's meal tray. DA 2 was asked to remove Resident 100's meal tray from the meal delivery cart and check it for accuracy. DA 2 reviewed the lunch meal tray and had not identified any concerns. DA 2 was asked to review the menu extension that indicated cardiac/heart healthy: No salt packet ., and DA 2 stated, New to me. DA 2 verified that he had placed the salt packet on the meal tray and verified he was unaware that residents on a heart healthy diet should not be served a salt packet according to 555762 Page 18 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0803 the menu. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/08/23, at 10:31 a.m., with Dietary Manager (DM), DM stated, a salt packet should not be on the meal tray with diet orders for heart healthy diet. DM verified the therapeutic heart healthy menu was not followed for Resident 100. Residents Affected - Some During a review of Resident 100's Diet Order (DO), dated 1/17/2023, the DO indicated, Low fat/low chol [cholesterol], NAS [no added salt], regular texture thin liquids. During a review of the facility's policy and procedure (P&P) titled, Section 2: Diets & Menus Menu Extensions/Diet Spreadsheets, dated 1/2016, the P & P indicated, Policy: Menu extensions are to be available, referred to, and followed with each meal that is prepared and served. Therapeutic menus will be written for all diets served in the facility. Procedures: 1. Each employee is responsible for following the prepared menu extensions. 2. It is the management team's duty to ensure that the menu extensions are accurate and updated as needed. Management team will provide menu extensions for every serving area. 3. When serving, the employee refers to the menu extensions to ensure that the proper portion sizes and diet needs are being met . During a review of the facility's policy and procedure (P&P) titled, Section 8: Nutrition Care Diet Orders, undated, the P & P indicated, Policy: The Food & Nutrition Services Department will maintain a record of the current physician prescribed diet order for each resident to ensure resident meal services are provided in accordance with the current diet order. 555762 Page 19 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure puree standardized recipes were followed during the puree diet meal preparation for one of one sampled residents (Resident 6) which could decrease nutritive value of the puree meal. Residents Affected - Few Findings: During an observation on 02/07/23, at 11:57 a.m., in the main kitchen, lead cook (LC) was observed to obtain chicken noodle soup from a pot over the stove range. LC placed the chicken noodle soup in a measured pitcher to 50 cc (cubic centimeter). LC then used a 2-ounce (oz.) black scoop to add three scoops of thickener for a total of 6 oz. of thickener. LC stated there was one resident (Resident 6) on a puree diet, but he made two portions just in case. During an observation on 02/07/23, at 12:05 p.m., in the main kitchen, LC was observed adding two portions, 4 ounces per portion, of cooked Italian blend vegetables into a large bowl. LC went to the stove range and was observed using a ladle to add hot water. The ingredients in the bowl resembled the appearance of a soup. LC was observed using the 2 oz. black scoop to add thickener, and he did that three times. LC then placed the ingredients in the food processor to obtain a puree consistency. LC was asked to confirm the ingredients and quantity that was used, and LC stated, he used two portions of the cooked vegetables (4 oz. each), 4 oz. of hot water that he pointed to over the stove range, 1 oz. of butter and 3 scoops of thickener (2 oz. per scoop) to make two portions of puree vegetables. During an interview on 02/07/23, at 12:10 p.m., with LC, LC was asked if there were puree recipes for the items he just prepared, and LC stated, Yes, there in, a binder. He grabbed a binder from a top shelf above his cooking area. LC stated the DM could help locate the puree recipes located in the binder. During a concurrent interview and record review on 02/08/23, at 10:28 a.m., with DM, the puree recipe for the puree vegetables was reviewed. The puree recipe was developed for six, 4-ounce sized portions and indicated to use 5 ounces of hot water with 1 1/2 pounds [24 ounces] of Italian blend vegetables. The recipe then indicated, In a food processor, add vegetables and hot water. Process for 2 to 3 minutes, or until smooth. The DM verified there was no direction in the puree recipe to add thickener, nor to add thickener to the chicken noodle soup. The DM stated the puree recipes were not followed and should have been. The DM verified excessive amount of thickener could displace nutrients and decrease nutritive value. During a review of Resident 6's Diet Order (DO), dated 4/14/2022, the DO indicated, Pureed Diet. During a review of the facility's policy and procedure (P&P) titled, Menus Production Systems - SS-505, dated 3/2010, the P&P indicated, Policy: A production system will be compiled by the General Manager and will be utilized by all personnel involved in daily food production ., Procedure: .Standardized recipes will be used for all menu items . 555762 Page 20 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

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 one of 19 sampled residents (Resident 18) received food in the form needed to meet the resident's nutritional needs per the diet order and speech therapist assessment. As a result of kitchen staff not following the diet order, this placed the resident at an increased risk for choking and/or difficulty with consuming adequate nutrition. Findings: During a concurrent observation and interview on 02/06/23, at 12:29 p.m., with Registered Dietitian (RD), in the hallway, Resident 18's lunch meal tray was observed by the RD on the meal delivery cart. RD observed an intact whole sandwich on Resident 18's meal tray and compared the uncut sandwich with the diet order on Resident 18's meal tray ticket that indicated Bite Sized. The RD stated, she would leave the meal tray on the meal delivery cart to follow up with the Speech Therapist (ST) to determine if the resident should have been served a whole, unchopped, sandwich by dietary staff. During an interview on 02/06/23, at 03:51 p.m., with RD, RD stated, she checked with ST and verified dietary staff should not have provided an intact, whole sandwich to Resident 18 since the diet order indicated bite sized. RD acknowledged that dietary staff should follow the diet order listed on the meal tray cards to ensure food leaving the kitchen was in the form to meet the resident's nutritional needs. During a concurrent observation and interview on 02/07/23, at 1:02 p.m., with Dietary Aide (DA) 2, in the main kitchen, Resident 18's lunch meal tray was observed on the meal delivery cart. DA 2 observed Resident 18's lunch meal tray that included a chopped salad and a side dish of two slices of avocado cut lengthwise, not chopped. DA 2 was asked if the avocado slices needed to be chopped due to the diet order indicating bite sized. DA 2 stated, Oh, I don't know. DA 2 verified it was his role to place the side dish of avocado on the meal tray. During a concurrent observation and interview on 02/07/23, at 1:02 p.m., with Dietary Manager (DM), in the main kitchen, DM observed Resident 18's side dish of avocado slices on the meal tray, and DM stated, there was not direction on the meal tray ticket to indicate the order of bite sized did not need to be followed for the avocado, and he informed the cook to chop the avocado. DM added, I'll check with ST. During a review of Resident 18's Diet Order (DO), dated 11/18/2022, the DO indicated, Soft Bite Size, Continue thin liquids. During a review of Resident 18's Interdisciplinary Nutrition Care Plan (IDT NCP), labeled as Active (Current), indicated, Underweight related to inability to consume sufficient energy ., Interventions .soft and bite sized . During a review of Resident 18's Dysphagia Therapy; Swallowing Eval [evaluation] (DT) notes, dated 11/18/22, the DT notes indicated ST had the diet order changed to soft and bite sized 6 (SB6) to help with safe chewing and swallowing. 555762 Page 21 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the Academy of Nutrition and Dietetics Nutrition Care Manual (NCM), dated 2023, the Soft & Bite Sized 6 diet (SB6) definition included, The Level 6 Soft and Bite-Sized diet is prescribed for people who have difficulty chewing hard, tough, stringy or crunchy food and are unable to safely bite off pieces of food. Some chewing ability is required to break food further into pieces and to move food around for a safe swallow. This diet requires a texture modification so that foods are soft, tender, moist and have no separate thin liquids. Foods should have a particle size no larger than 1.5 centimeters (cm) x 1.5 centimeters. Foods should further meet the complete descriptive and testing specifications of the International Dysphagia Diet Standardisation Initiative (IDDSI, 2019a; IDDSI, 2019b). During a review of the International Dysphagia Diet Standardisation Initiative, the SB6 diet indicated, For adults the lump size is no bigger than 1.5cm x 1.5cm, which is about the width of a standard dinner fork .examples of food to avoid .lettuce. During a review of the facility's policy and procedure (P&P) titled, Section 8: Nutrition Care Diet Orders, undated, the P & P indicated, Policy: The Food & Nutrition Services Department will maintain a record of the current physician prescribed diet order for each resident to ensure resident meal services are provided in accordance with the current diet order. 555762 Page 22 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 maintain safe and sanitary food handling practices when: 1. Expired peeled, chopped garlic was available for use in the refrigerator. 2. TCS food (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) was not documented on the facility's cooling log to ensure food safety. 3. A scoop was stored directly on rice in an ingredient bin increasing the risk of cross contamination. 4. A dietary employee failed to identify the proper sanitizing chemical. 5. Food delivery boxes were stored directly on the floor and then placed in the refrigerator, freezer and/or dry food storage room. These failures had the potential to result in foodborne illnesses. Findings: 1. During a concurrent observation and interview on 02/06/23, at 9:45 a.m., with Lead [NAME] (LC), in the walk-in refrigerator in the main kitchen, LC observed a five pound container of peeled garlic labeled as prep 1-21-23, Discard by 2-4-23. Another smaller container of chopped garlic was labeled as Opened 1/29/23 1:34 p.m., Discard 2/5/23 1:34 p.m. LC stated, the garlic was expired and should not be available for use. During a review of the facility's policy and procedure (P&P) titled, C-26 Date Marking Ready to Eat TCS .Foods, dated 4-1-22, the P&P indicated, Refrigerated, ready to eat, .food prepared and held in a food establishment must be clearly marked with a consume by/discard date . 2. During a concurrent observation and interview on 02/06/23, at 9:45 a.m., with Lead [NAME] (LC), in the walk-in refrigerator in the main kitchen, LC observed a large pan of cooked pasta labeled as 2-6-23 9:45 a.m. LC stated, he cooked the pasta that morning and it was for macaroni and cheese for the residents lunch today. During a concurrent observation and interview on 02/06/23, at 10:03 a.m., in the presence of the Registered Dietitian (RD), LC was asked for the cool down log. LC stated, We don't have a cool down log. LC stated the three pounds of pasta was done cooking at 9 a.m. that morning. LC stated he put the pasta on ice and the pasta was less than 41 degrees F in 18-20 seconds. Concurrently, LC used a digital thermometer and inserted the thermometer in the pasta, and LC stated, It's 46.4 degrees F. LC verified he had not documented the cool down process on a cool down log. Concurrently, the RD verified pasta is a TCS food, and RD stated, she did not know if the staff had a cool down log. The RD stated the Dietary Manager (DM) would know as she was the clinical Dietitian. 555762 Page 23 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/8/23, at 10 a.m., with DM, DM stated, the cook should have begun documenting the cool down process for the pasta on the cooling log. During a review of the facility's policy and procedure (P&P) titled, C-23 Cooling and Chilling, dated 4-01-22, the P&P indicated, Cooked TCS/PHF [potentially hazardous food] food shall be cooled: from 140 degrees F to 70 degrees F within 2 hours or less and then to 40 degrees F or below with an additional 4 hours (total maximum cooling time 6 hours) .Cooling and chilling temperatures must be taken with a calibrated thermometer and recorded on the HACCP [Hazard Analysis Critical Control Point] Cooling and Chilling log . 3. During a concurrent observation and interview on 02/06/23, at 10:02 AM, with Registered Dietitian (RD), in the main kitchen, a scoop was observed touching uncooked rice inside a dry storage ingredient bin. The RD verified the scoop should not have been stored touching the rice as it was a source for potential cross contamination. Concurrently, another ingredient bin was observed to have a sign posted on the lid of the bin that indicated, Do Not Leave Scoop In Bin. During an interview on 2/8/23, at 10:02 a.m., with DM, DM verified the scoop should not have been stored inside the dry ingredient bin touching the rice. 4. During a concurrent observation and interview on 02/07/23, at 09:39 a.m., with dish washer (DW) 1, in the main kitchen, DW 1 was observed using a red cloth and wiping down a utility cart. DW 1 then proceeded to load dishes into the dish machine. In the presence of a dietary aide (DA) 3 translating in Spanish for DW 1, DW 1 stated, he was not done cleaning the utility cart as he still needed to sanitize it. DW 1 held up a bottle titled Orange Oasis Cleaner and stated that is what he used to sanitize. The Dietary Manager (DM) was present for the above observation and interview. During an interview on 02/07/23, at 9:41 a.m., with DM, DM stated, the Orange Oasis 137 Orange Force was a multipurpose cleaner and not a sanitizer. DM verified it was DW 1's assigned task to clean and sanitize the utility carts. DM stated, DW 1 should have sanitized the utility cart after cleaning using a quat (quaternary ammonium compounds) 146 sanitizer that was available in the kitchen. The DM provided a Sanitizer Solution Log- U.S. that indicated, Required concentration for Oasis 146: must be set at 150-400 ppm [parts per million] for all dispensing equipment, use on stationary equipment, spray bottles, solutions for storing wiping cloths. During a review of the facility's policy and procedure (P&P) titled, C-8 Preventing Cross Contamination, dated 08/01/2020, the P&P indicated, .Utensils and equipment used for both raw and ready to eat foods must be cleaned and sanitized between uses . 5. During a concurrent observation and interview on 02/07/23, at 09:30 a.m., with Dietary Aide (DA) 3, in the main kitchen, DA 3 was observed receiving a food delivery supply in which the boxes of food were placed directly on the kitchen floor. DA 3 verified the cardboard boxes of food would be placed directly on the shelves inside the refrigerator, freezer and dry food storage room, as applicable. One of the boxes of food stored directly on the floor was a cardboard box labeled as pasteurized shell eggs, and another cardboard box was labeled as [NAME] Sure Crisp (French fries). During an interview on 2/8/23, at 10:02 a.m., with DM, DM stated they did not have a policy that indicated the food delivery cannot be placed directly on the floor, in which that same cardboard box is then placed on the food storage shelves. 555762 Page 24 of 25 555762 02/10/2023 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the Food and Drug Administration (FDA) Food Code, dated 2022, the FDA Food Code included, Employees are verifying that foods delivered to the food establishment are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination . (FDA Food Code 2022, 2-103.11) During a review of the FDA Food Code Annex 2-103.11, the FDA Food Code Annex indicated, When food and other purchased goods are delivered and placed into designated locations within the food establishment .the Person in Charge must make sure food employees inspect such product and verify that it is from the appropriate supplier, is in the desired condition, and was delivered to a proper storage location. Distributors deliver and place food and other goods in refrigeration units, freezers, and dry storage areas for confirmation of receipt and inspection by employees immediately upon arrival to the food establishment ., Upon delivery, all food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41°F or below. Likewise, if the food product is frozen, it must be placed into the freezer. 555762 Page 25 of 25