Valle Verde Health Facility

F-F812)

2. Registered Dietitian (RD) 1 and Corporate Registered Dietitian (CRD) failed to demonstrate appropriate skill set to carry out the functions of the food and nutrition service when RD 1 and CRD did not identify and communicate to leadership that an obsolete therapeutic diet NCS (No Concentrated Sweets) was being implemented for diabetes care for residents. There were eight residents residing at the facility with a therapeutic diet order for NCS as follows: Resident #51, Resident #1, Resident #45, Resident# 17, Resident #30, Resident #43, Resident # 26, and Resident # 9.

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 to provide clinical and technical direction to meet the nutritional needs of residents with diabetes.

Findings:

1. During the annual recertification survey from 1/07/25-1/10/25, multiple issues surrounding the delivery of dietetic services were unmet in relation to:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 1a. During an observation on 01/07/25 at 09:39 a.m., inside the walk -in refrigerator in the kitchen, there was cooked macaroni style pasta, stored in a large, deep container, labeled as prepared on 01/07/25 for soup Level of Harm - Minimal harm or and use by 1/9/25. DSS confirmed the soup would be served to residents. potential for actual harm

During an observation on 01/07/25 at 09:57 a.m. inside the walk-in refrigerator in the kitchen, a large pan Residents Affected - Many size of 4 (inch) deep of cooked quinoa labeled as Prepped Salad, prepared on 1-6-25 at 6:23 p.m., and Use By 1-10-25 at 6:23 p.m., and another large 4 pan of cooked plain quinoa labeled as cooked on 1-6-25 at 6:23 pm an Use By 1-10-25 at 6:23 pm. DSS stated the quinoa would be served to residents as a cold salad.

During a concurrent observation and interview on 01/07/25 at 10:20 a.m., with Lead [NAME] (LC) 2, in the kitchen, there was a cool down log posted on the wall with one entry made on 01/02/25 for penne pasta. LC2 confirmed the only entry on the cool down log was on 01/02/25.

During a concurrent observation and interview on 01/07/25 at 10:23 a.m., with DDS and LC2, in the kitchen, LC2 said he cooked the macaroni pasta that morning at 05:45 a.m. and placed it on a 2 (inch) sheet pan to chill. Two hours later he checked the temperature, and it was 53 degrees F (Fahrenheit). He checked the temperature again 2 hours later (4 hours from the time it was cooked) and the temperature was 38 degrees F. LC2 stated he did not document the cool down temperatures on the cool down log. LC2 was asked to check the temperature of the cooked macaroni pasta and the temperature read from the digital thermometer was 74 degrees F. LC2 calibrated the thermometer in ice water to 32 degrees F, and stirred the pasta and then re-checked the pasta temperature, and it read 67.8 degrees F.

During a concurrent observation and interview on 01/07/25 at 3:20 p.m., with DDS in the walk-in refrigerator,

the same macaroni pasta from the morning remained available for use. DDS verified it was the same macaroni pasta that had a temperature (temp) of 67.8 degrees nearly 5 hours after the initial cool down. DDS was asked to get the cool down log for further discussion of the events of the morning, in the presence of Sous Chef (SC). The cool down log now showed the macaroni pasta was 53 degrees F at 5:45 a.m. on 1/07/25 and two hours later being 38 degrees F. DDS was asked what he thought about the documentation. DDS stated he was unaware that LC 2 documented that on the cooling log after surveyors left the kitchen in

the morning. DDS was asked if the information documented was accurate and he stated he would not know without speaking to LC 2 because he did not know if LC 2 further cooled down the macaroni pasta, on ice for example, after the temperature was observed to read 67.8 degrees F. After further discussion, DDS confirmed he observed the temperature reading of 67.8 degrees F for the macaroni pasta close to 5 hours

after the initial cooling began and was unable to explain why the cooling log indicated it was 38 degrees F. DDS verified that toxin formation could occur if the initial 2 hour cool did not achieve a temperature of 70 degrees F or less, and that even a TCS food reached 41 degrees F or less in an additional 4 more hours the food may still be unsafe since toxins are heat-resistant. DDS acknowledged he had not taken immediate corrective action to direct staff to throw out the macaroni pasta since he was unable to verify it was cooled down safely, after it was identified five hours earlier in the day at 10:23 a.m., and may cause the highly susceptible residents to get foodborne illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a concurrent observation and interview on 01/07/25 at 3:32 p.m., with DDS in the walk-in refrigerator,

the same pan of cooked quinoa in which the DDS was aware was not documented as being cooled down Level of Harm - Minimal harm or safely on the cool down log, was now prepared into a Moroccan Quinoa Beet Salad on the resident's select potential for actual harm menu for lunch and dinner on 01/8/25. DDS verified quinoa was a TCS food that would need to be cooled down per established professional standards for food safety. DDS stated he was not able to verify the Residents Affected - Many Quinoa Beet Salad was safe to serve as there was no documentation of the cool down process on the cool down log and stated it should be thrown out, however, this was identified five hours earlier without immediate corrective action during which time the kitchen staff further prepared the plain quinoa into a beet salad.

During an interview on 01/08/25 at 11:16 a.m. with DDS, DDS stated the Registered Dietitian (RD) 1 had input on menus, otherwise RD was mainly clinical nutrition care. DDS stated, RD 1 walked through the kitchen on occasion but not on a scheduled, formalized, routine basis. DSS stated that was one of his upcoming plans was to get himself, the Executive Chef that was hired one month ago and RD 1 on a routine formalized schedule to conduct audits of food safety and sanitation, among other agenda items.

During a review of the FDA Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures, 70o [degrees]F - 125oF), is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.Safe cooling requires removing heat from food quickly enough to prevent microbial growth. The Food Code provision for cooling provides for cooling from 135 F to 41 F.in 6 hours, with cooling from 135 F to 70 F in 2 hours.The initial 2-hour cool is a critical element of this cooling process. Conversely, if cooling from 135 F to 41 F.is achieved in 6 hours, but the initial cooling to 70 F took 3 hours, the food safety hazards may not be adequately controlled.

During a concurrent interview and record review on 01/08/25 at 12:37 p.m. with DDS, DDS stated he had the cooks make a new batch of quinoa yesterday on 01/07/25 in the afternoon, and he verified the cool down process was done correctly. The Cooling Log (CL), dated 01/07/25, indicated the initial cooling process began at 4:30 at 191 degrees F and was 66 degrees F 2 hours later at 6:30 and at 9:00 the quinoa was 38 degrees F, initialed by a lead cook (LC) 3 as AA. DDS verified only the cook position cools down food. DDS was asked what time the cooks go home and he stated between 7:30 p.m. to 8:00 p.m. DDS was asked if 9:00 meant 9:00 a.m., and DDS stated, he did not know, maybe AA (LC 3) stayed later. DDS stated, I don't know and she is on vacation for the rest of the week.

During a review of LC 3's Employee Timecards (ETC), dated Tues 1/07, the ETC indicated LC 3 clocked out of work at 7:20 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a review of the facility's policy and procedure (P&P) titled, Food Handling Guidelines (HACCP), dated 01/2025, the P&P indicated, Cooling of potentially hazardous cooked foods: Food shall be cooled from 135F Level of Harm - Minimal harm or to 70F as measured at its center within two hours from 70F to 41F within an additional four hours for a total potential for actual harm cooling time of six hours or less. Use the Cooling Log form .to document the temperature of the food at the following times: when placed in cooling equipment, and then at 2 hours and 6 hours after placing in cooling Residents Affected - Many equipment. Foods that have not cooled to 70 degrees F within 2 hours of being placed in the cooling equipment: reheat once to 165 degrees F and re-cool.Food that is not below 41 degrees F at 6 hours must be discarded.

During a review of the FDA Food Code (FDAFC), dated 2022, the FDAFC indicated, The person in charge shall ensure that employees are using proper methods to rapidly cool time/temperature control for safety foods that are not held hot or are not for consumption within 4 hours, through daily oversight of the employees' routine monitoring of food temperatures during cooling.

During an interview on 01/10/25 at 2:40 p.m. with RD 1, in the presence of DDS, RD 1 stated she has been employed at the facility for three months. RD 1 stated she had completed a sanitation and food safety audit of the kitchen soon after hire for learning of her new job duties. RD 1 stated at that time, she had identified incomplete documentation of cool down but had not had followed up as of yet.

1b. During an interview on 01/07/25 at 10:51 a.m. with DDS, DDS stated ice obtained from an ice machine located in a pantry adjacent to nursing station 1 was used in the dining room located at the health center (SNF) for residents.

During an interview on 01/09/25 at 10:06 a.m. with LN 1 at nursing station one, LN 1 stated, the ice machine

in the pantry was used for residents water pitchers to provide ice water for hydration.

During a concurrent observation and interview on 01/09/25 at 10:45 a.m. with DDS and Maintenance Supervisor (MS) in the nurse's station pantry room, DDS observed the ice-machine with thick build-up of white and blackish/brownish colored substance where the ice and water dispenser chutes get secured in place. DDS stated it looked like hard water deposits and without swabbing and culturing the area, the dark spots look like mold. DDS acknowledged the dispenser chutes did not look sanitary. DDS and MS verified that neither kitchen staff nor maintenance staff had a role in cleaning of the ice-machine located in the nurse's station pantry room in between the outside contracted vendor that cleans the machine on a semi-annual basis.

During a concurrent interview and record review on 01/10/25 at 2:30 p.m. with DDS, the main kitchen's Ice Machine Cleaning Log (IMCL), dated 2024 was reviewed. The IMCL indicated, Bi-annual services provided by outside vendor. Monthly cleaning instructions by Nutrition when not serviced by maintenance; 1. Empty out all ice, 2. Sanitize and wipe down inside of bin/machine, 3. Sanitize and wipe down ice chute, 4. Wipe down exterior of machine. DDS verified that system for the ice machine located in the kitchen kept that ice-machine in a sanitary condition. DDS acknowledged ice was food and even though the facility had not assigned in between cleaning to the food and nutrition services department that he could have lend his knowledge and advice as a Certified Dietary Manager to the facility leadership as the facility was a whole unit versus departmentalization.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 1c. During a concurrent observation and interview on 01/07/25 at 09:39 a.m., with DDS in the dry food storage area, a kitchen staff titled [NAME] (PO) was observed sweeping. There was an extensive quantity of Level of Harm - Minimal harm or debris observed on the floor behind, and under, metal racks. PO stated the dry food storage room was to be potential for actual harm swept and mopped one time a day. PO stated there was not a log or requirement for him to sign or initial anywhere after he completed the task. Residents Affected - Many

During a concurrent interview and record review on 01/07/25 at 03:37 p.m. with DDS in the kitchen, DDS reviewed the Master Cleaning Schedule, dated 1/5/25, that indicated the floors were to be cleaned on Monday (1/6/25) and on Friday (1/10/25). DDS stated the cleaning of the floor task was missed on 1/6/25 as

it was expected for staff to initial once the task was completed.

During a review of the facility's job description titled [NAME] that was provided for PO, the JD was signed by PO on 8/23/24.

During a concurrent interview and record review on 01/10/25 at 2:40 p.m. with DDS, DDS was asked if he conducted orientation training and/or competency evaluation upon hire for PO. DDS stated he had a signed job description but did not have My First 5 on file which was a list of job duties specific to the employee's job title to go over with new staff on their first 5 days of employment. DDS stated, it was missed.

During a review of the facility's policy and procedure (P&P) titled, Orientation and Education; On-The-Job Training, dated 1/25, the P&P indicated, Policies: On-the-job training is implemented for the purpose of: Task-related training of new associates; Retraining for different/additional position(s); Correcting deficiencies

in job skills for current position.Improving a function identified through performance improvement process or evaluation. Procedures: .Evidence of training to ensure competency in the new role is available in the associate's personnel file.

During a concurrent observation and interview on 01/08/25 at 11:11 a.m., with DDS in the kitchen near the stove range, observed a floor sink (drain), and the floor located by the floor sink, with buildup of black grime and dried food debris. DDS stated it was not sanitary.

During a review of the Master Cleaning Schedule (MCS), dated 1/5/25, the MCS indicated the Drains were to be cleaned on 1/5/25 and on 1/7/25, the initial column for both days was blank.

During a concurrent observation and interview on 01/08/25 at 11:14 a.m., with DDS in the kitchen, clean food preparation equipment, such as pots, food holding pans, pitchers were stored directly on shelving that had a buildup of black grime. In addition, there was a worn and discolored pitcher, and a pan with deep scratches that was no longer a smooth cleanable surface. DDS stated the clean dishes were not stored in a sanitary manner. DDS verified some of the foodservice equipment needed to be replaced.

During an interview on 1/08/25 at 10:55 a.m. with DDS, DDS stated he was the person responsible for the entire food service operation including the day to day operations to ensure food safety and sanitation of the main kitchen and the health center (SNF). DDS stated due to the size of foodservice operations that occurs at multiple locations on the CCRC campus he relied heavily on the Executive Chef and Sous Chef for monitoring, identifying and reporting to him any concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 1d. During the recertification survey from 01/07/25 to 01/10/25 there were further unsanitary conditions related to clean foodservice equipment stored on unclean shelves in the kitchen, leaking pipes located in the Level of Harm - Minimal harm or 3-compartment sink room and in the dishmachine room, and multiple rat traps located in the dry food storage potential for actual harm room of the kitchen in which the rodent bait was not contained in a covered, tamper-resistant bait station as required by the FDA Food Code, dated 2022. Residents Affected - Many

During an interview on 01/10/25 from 2:20 to 3:00 p.m. with DDS, in the presence of RD 1, DDS verified the above findings and again stated that he was the person responsible for the daily operations of the foodservice to ensure food safety and sanitation from the time the food arrived to the CCRC to the time it was served to residents in the Health Center (SNF). DDS stated he delegated a lot of tasks to the Executive Chef (EC) and needed to rely on him heavily for daily oversight of staff and implementation of facility's policies and procedures and for EC to identify and report to him any concerns that need to be addressed within the entire foodservice operation. DDS stated he was in the kitchen daily and conducted daily briefings with kitchen staff and with a Dining Services Manager, and a Nutrition Care Supervisor, however, the CCRC foodservice operation was extensive as the non-SNF licensed premise also had multiple eating areas with kitchens and other kitchen staff.

During a review of the facility's job description titled, Director of Dining Services, undated, the JD indicated, Leading Food & Beverage Operation: .Ability to quickly evaluate personnel, operations, and culinary situations and make appropriate recommendations to person(s) involved.Perform daily walk-through to ensure full compliance with Department of Health regulations and [name of contracted services] Group standards. Directs and conducts safety, sanitation, and maintenance programs. Ensures that regular, ongoing communication occurs in all areas of food and beverage by leading pre-meal briefings and staff meetings. Advise and update the executives, supervisors, co-workers, and subordinates on relevant information in a timely manner by telephone, in written form, e-mail, or in person.establish goals including performance goals.Identifies the developmental needs of others, coach, and mentor team members by providing feedback and training to achieve performance objectives.

2. During an observation on 01/08/25 at 11:46 a.m. in the dining room, Resident 43's meal tray ticket (MTT) indicated, Texture: Regular, Special Diets: NCS [no concentrated sweets], Vegetarian Lacto-Ovo [eats dairy products and eggs but not meat], Alerts: 1/2 portion of dessert, No Concentrated

Sweets.

During a review of Resident 43's Admission Record (AR), dated 06/13/2023, the AR indicated, Resident 43 had Type 2 Diabetes Mellitus.

During a review of Resident 43's Order Details (OD), dated 7/22/2024, the OD indicated, Diet Type: No Concentrated Sweets (NCS).

During a concurrent observation and interview on 01/08/25 at 11:48 a.m. with Registered Dietitian (RD) 1 in

the dining room where dining staff were plating Resident 30's lunch plate from a steamtable, Resident 30's MTT was reviewed. RD 1 stated Resident 30 was not served dessert because he did not want dessert today as he filled out his own select menu.

During a review of Resident 30's Admission Record (AR), dated 07/22/2024, the AR indicated, Resident 30 had Type 2 Diabetes Mellitus.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a review of Resident 30's Order Details (OD), dated 7/22/2024, the OD indicated, Diet Type: No Concentrated Sweets (NCS). Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 01/08/25 at 11:48 a.m. with RD 1 in the dining room, RD 1 reviewed the planned menu that included a column titled CCD. RD 1 stated CCD meant consistent Residents Affected - Many carbohydrate diet, but the facility treated the CCD diet as a NCS diet. RD 1 stated the doctor's order NCS diets for residents with diabetes in the medical record, not CCD diets. RD 1 stated the kitchen staff are trained to serve the NCS diet order by serving 1/2 portion of dessert that was planned for the regular (non-therapeutic) diet, when the resident select's dessert from their select menu. RD 1 reviewed the lunch menu under the column CCD that listed Same as Base; 1 carb [carbohydrate] and RD 1 stated that meant Chocolate Mousse; 1/2 cup or for the Snickerdoodles [cookies] 1 [one] each should have been served the same way the regular diet would have received the dessert if the menu was followed. RD 1 stated the planned menu was not followed because the facility's diabetic diet was NCS and not CCD.

During a concurrent interview and record review on 01/09/25 at 3:45 p.m. with RD 1 and Corporate Registered Dietitian (CRD), the facility's diet manual, approved on 6/17/24 and 1/10/25, titled Indiana Diet Manual incorporated a link to also include the NCM (Nutrition Care Manual) from AND (Academy of Nutrition and Dietetics) into the facility's approved diet manual per CRD. A policy and procedure on Diet Manual was requested but was not provided.

During an interview on 01/09/25 at 4:00 p.m. with RD 1 and Corporate Registered Dietitian (CRD), RD 1 and CRD both stated the only diabetic diet that was used at the facility was NCS. Both RD 1 and CRD were unaware the NCS diet was no longer recognized as a therapeutic diet for the care of diabetes. Both RD 1 and CRD were asked to review obsolete (out-of-date) diet orders listed in their facility's diet manual portion from the NCM and determine as to whether the facility was implementing therapeutic diet for diabetes care in accordance with established standards of practice.

During a review of a document titled CCD/No Concentrated Sweets (NCS) provided by the facility from the facility's Indiana Diet Manual, the CCD/,NCS indicated, How to order the diet: Order as No Concentrated Sweets (NCS) diet.References: Acad Nutr Diet. [Academy of Nutrition & Dietetics] 2012.

During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2025,

the NCM indicated, Use of the noted obsolete terms and associated recommendations should be avoided. Obsolete diets and diet terminology for condition Type 1 Diabetes and Type 2 Diabetes: No Concentrated Sweets diet, No Sugar Added, Low Sugar, Liberal Diabetic Diet.With regard to the no concentrated sweets, no sugar added, low sugar, and liberal diabetic diets.None of these approaches to food and meal planning is appropriate because each unnecessarily restricts sucrose.

According to the facility's Diet Type Report (DTR), dated 1/10/25, DTR indicated there were eight residents residing at the facility with a NCS diet order as follows: Resident #51, Resident #1, Resident #45, Resident# 17, Resident #30, Resident #43, Resident # 26, and Resident # 9.

During an interview on 01/09/25 at 04:15 p.m. with RD 1 and CRD, CRD stated she would work on changing

the facility's system related to using NCS diets and practices to care for residents with diabetes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), dated 2025,

the NCM indicated, The name of the diet used in your facility should no longer emphasize the restriction of Level of Harm - Minimal harm or sugar or sweets but rather emphasize consistent carbohydrates. No foods are omitted from the consistent potential for actual harm carbohydrate meal plan unless required by a comorbidity [presence of two or more diseases or conditions]. A consistent carbohydrate diet requires initial and ongoing collaborative planning with the patient to incorporate Residents Affected - Many their individualized goals, preferences, and any comorbidities.

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 .

During a review of the facility's policy and procedure (P&P) titled, Resident Meal Service, dated 1/25, the P&P indicated, Policies: Residents will be offered menu choices for all meals, beverages and snacks and are based on their prescribed diet, food preferences.and consistent with their plan of care.

During a review of the facility's policy and procedure (P&P) titled, Resident Menu Planning, Approval and Revision, dated 1/24, the P&P indicated, Policies: Menus are written to meet the nutritional needs of the resident population in accordance with established national guidelines.Dietitian approves the menu nutritional adequacy with established national guidelines and refers to menu guidelines.

During a review of NCM, dated 2025, NCM indicated RDs had a role in menu planning and diet manual implementation,.The NCM Diet Manual is the guide for menu planning.Review Obsolete Diets to ensure you avoid using these diet terms in your facility ' s accepted diet terminology.

Diet names used in all areas should match: medical record documentation (electronic or paper), printed menus or tray tickets, diet manual, documents used by the kitchen staff (i.e. menu spreadsheets), diet guide sheets, and policies and procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 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. Level of Harm - Minimal harm or potential for actual harm 27157

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the planned menu for the therapeutic Mechanical [Mech] Soft Chopped (Level 6) [Level 6 - Soft & Bite-Sized (SB6)] diet (SB6 diet; food may be used when not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow) was developed and prepared in accordance with established national guidelines, IDDSI (International Dysphagia [difficulty swallowing] Diet Standardization Initiative), when the facility's menu modified the Level 6/SB 6 framework by incorporating unsafe foods based on an out-of-date Mech Soft Chopped diet from an obsolete National Dysphagia Diet (NDD). There were seven residents residing at the facility with a Mech [mechanical] Soft diet order that were provided Mech Soft Chopped (Level 6) menus as follows: Resident # (number) 2, Resident #33, Resident #45, Resident #1, Resident # 6, Resident #11, Resident #16.

As a result, the facility co-mingled an out-of-date therapeutic diet Mech Soft Chopped (NDD) that was no longer nationally recognized with an IDDSI Level 6 diet that had the potential to lead to confusion and errors

in diet texture.for patients with dysphagia. Such errors have previously been associated with adverse events including choking. per IDDSI.

Findings:

1. During a concurrent observation and interview on 01/07/25 at 12:10 p.m. with Registered Dietitian (RD) 1

in the dining room, residents with meal tray tickets that listed a diet order for mechanical soft were observed served a whole Hawaiian sweet roll and cilantro rice as listed on the Mechanical Soft Chopped (Level 6) menu. RD 1 stated residents could have a whole roll and rice if they chose that from their select menu for Level 6 IDDSI diets. RD 1 reviewed the planned menu for lunch under the column titled Mechanical [mech] Soft Chopped (Level 6). The Mech Soft Chopped Level 6 column on the menu indicated Same as Base: spoodle [serving utensil]-4oz for cilantro rice, and Same as Base for Hawaiian Sweet Roll. RD 1 stated that meant residents with a Level 6 IDDSI diet order would receive the same cilantro rice and whole Hawaiian sweet roll as those residents on a regular diet.

During a concurrent interview and record review on 01/09/25 at 12:16 p.m. with RD 1, RD 1 reviewed the planned menu that listed Mechanical Soft Chopped (Level 6). RD 1 stated, the menu was not in transition to IDDSI, that it

was already in place.

During a concurrent interview and record review on 01/09/25 at 3:30 p.m. with RD 1, RD 1 was asked if the Mechanical Soft Chopped (Level 6) menu was in line with IDDSI standards of practice for Level 6 diet, also known as Soft & Bite-Sized Diet (SB6), and RD 1 stated, I think so. RD 1 reviewed Level 6/SB6 diet on-line at IDDSI.Org. RD 1 stated, I'm just not sure what 'NO REGULAR DRY BREAD' means. RD 1 stated the cilantro rice as served was not allowed on a Level 6/SB6 diet per IDDSI standards of practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a review of the IDDSI framework for Level 6/SB6, the Level 6/SB6 diet indicated, NO REGULAR DRY BREAD due to high choking risk! IDDSI indicated, As a general rule, bread products are considered a regular Level of Harm - Minimal harm or food texture (Level 7) and are not permitted at levels 6 (Soft & Bite-Sized). This decision is based on a potential for actual harm review of the choking literature, in which bread is frequently identified as a cause of choking. If a piece of bread or sandwich is pre-cut to fall below the maximum size guideline of Level 6 (1.5 cm [centimeter] for Residents Affected - Few adults), then a clinician might decide to allow it for some patients on a case-by-case basis. all foods (sandwiches included) need to meet the particle size requirements for Level 6 - Soft & Bite-sized. In order to avoid asphyxiation [when body does not receive enough oxygen when choking], particles should be small enough to pass through rather than block the trachea. The average tracheal [connects your voice box to your lungs] size for adult males is 22mm [millimeter] and for adult females is 17 mm. Particle sizes of 15 mm (i.e. 1.5cm) size are therefore more likely to pass through the trachea, than block it.

During a review of the IDDSI framework for Level 6/SB6, the Level 6/SB6 diet indicated, Rice should not. separate into individual grains when cooked and served. May require a thick, smooth, nonpouring sauce to moisten and hold the rice together.

During a review of the facility's recipe for Cilantro Rice, the recipe indicated, Fluffy [rice that has been separated into individual grains] rice with the enchanting flavor of Cilantro.

During a concurrent interview and record review on 01/09/25 at 3:45 p.m. with RD 1 and Corporate Registered Dietitian (CRD), the facility's diet manual, approved on 6/17/24 and 1/10/25, titled Indiana Diet Manual incorporated a link to also include the NCM from AND diet manual in the facility's approved diet manual per CRD. CRD verified the Hawaiian sweet role and fluffy rice were not allowed per IDDSI Level 6 diet which was the established standards of practice. CRD confirmed the facility's planned menu was comingling the out-of-date mechanical soft diet (National Dysphagia Diet (NDD)) aspects with aspects of the Level 6 IDDSI diet for residents with dysphagia. CRD stated we're still in the process of fully transitioning to IDDSI.

During review of the NCM from AND, dated 2024, the NCM indicated, Beginning October 2021, IDDSI will be

the only texture-modified diet recognized. The National Dysphagia Diet (NDD) and associated resources will no longer be included in the NCM. The NCM, under dysphagia condition, indicated, Refer to the following clinical practice guidelines for additional, more explicit information: International Dysphagia Diet Standardization Initiative (IDDSI).Transitioning texture-modified diets to the IDDSI framework. Determine which recipes and menu items are safe to serve at each IDDSI Level.

During a review of IDDSI.Org titled Guidelines For Use (GFU), dated 2024, GFU indicated, Supplementary Notice: Do not alter the elements of the IDDSI framework. Alterations may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

According to the facility's Diet Order Tally Report (DOTR), dated 1/10/25, DOTR indicated there were seven residents residing at the facility with a Mech [mechanical] Soft diet order as follows: Resident # (number) 2, Resident #33, Resident #45, Resident #1, Resident # 6, Resident #11, Resident #16.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a review of IDDSI's document titled Standards of Practice Regulatory Information for Long Term Care Facilities, Hospitals, Critical Access Hospitals, Home Health Agencies and Hospice, dated July 2021, Level of Harm - Minimal harm or indicated, The National Dysphagia Diet (NDD) is now outdated and International Dysphagia Diet potential for actual harm Standardization Initiative (IDDSI) will be the only professionally recognized texture modified diet framework as of October 2021.It is the only professionally- supported and evidence-based standard of practice. Residents Affected - Few

During a review of the facility's policy and procedure (P&P) titled, Resident Menu Planning, Approval and Revision, dated 1/24, the P&P indicated, Policies: Menus are written to meet the nutritional needs of the resident population in accordance with established national guidelines.Dietitian approves the menu nutritional adequacy with established national guidelines and refers to menu guidelines.

During a review of the facility's diet manual (DM), titled Indiana Diet Manual, approved on 6/17/24 and 1/10/25, the DM included, Mechanical Soft (Finely Chopped); Order as Mechanical Soft (chopped). Description: The diet is a modification of the Regular Diet for the edentulous resident who has difficulty chewing or swallowing.Foods Allowed: Soft breads and rolls, Moist bread dressing Foods Excluded:.Dry bread.Cooked rice .References: 1. Position of the Academy of Nutrition and Dietetics: Food and Nutrition for older adults.2012.

During an interview on 01/09/25 at 3:45 p.m. with RD 1 and Corporate Registered Dietitian (CRD), CRD stated the facility's diet manual titled Indiana Diet Manual incorporated a link to also include the NCM diet manual into the facility's approved diet manual that indicated the NDD, in which Mechanical Soft Chopped Diet was a Level 2 NDD diet, was no longer recognized for dysphagia treatment and had been replaced by established standards of practice IDDSI diets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50657

Residents Affected - Many Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service when:

1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent

the growth of bacteria) were not consistently and accurately cooled down to ensure food safety.

2. The ice machine, located in a pantry near a nursing station, utilized for residents was not maintained in a sanitary condition.

3. There were unsanitary conditions in the main kitchen related to:

3a. Kitchen floors with build -up of dried food debris.

3b. Floor drains with build- up of dried food debris.

3c. Clean equipment stored on unclean shelves.

4. There was a container of cooked pasta in the walk-in refrigerator in the main kitchen that was not dated.

5. Foodservice equipment was not maintained in good repair as evidenced by leaking pipes, located in the warewashing areas of the main kitchen, in which the water was pooled into a container which could attract pests such as insects and rodents.

6. Rodent bait stations were not covered posing a risk for cross-contamination of food-contact surfaces.

Findings:

1. During an observation on 01/07/25 at 09:39 a.m ., inside the walk -in refrigerator in the kitchen, there was cooked macaroni style pasta, stored in a large, deep container, labeled as prepared on 01/07/25.

During a concurrent observation and interview on 01/07/25 at 09:57 a.m., with the Director of Dining Services (DDS) inside the walk-in refrigerator, there was a size 400 pan (4 inch deep) of quinoa with a label indicating

it was cooked on 01/06/25 at 6:23 p.m. DDS confirmed it was cooked on 01/06/25 at the facility.

During a concurrent observation and interview on 01/07/25 at 10:20 a.m., with Lead [NAME] (LC) 2, in the kitchen, there was a cool down log posted on the wall with one entry made on 01/02/25 for penne pasta. LC2 confirmed the only entry on the cool down log was on 01/02/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a concurrent observation and interview on 01/07/25 at 10:23 a.m., with DDS and LC2, in the kitchen, LC2 said he cooked the macaroni pasta that morning at 05:45 a.m. and placed it on a 2 (inch) sheet pan to Level of Harm - Minimal harm or chill. Two hours later he checked the temperature, and it was 53 degrees F (Fahrenheit). He checked the potential for actual harm temperature again 2 hours later (4 hours from the time it was cooked) and the temperature was 38 degrees F. LC2 stated he did not document the cool down temperatures on the cool down log. LC2 was asked to Residents Affected - Many check the temperature of the cooked macaroni pasta and the temperature read from the digital thermometer was 74 degrees F. LC2 calibrated the thermometer in ice water to 32 degrees F, and stirred the pasta and then re-checked the pasta temperature, and it read 67.8 degrees F.

During a review of the FDA Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation

temperatures, 70o [degrees]F - 125oF), is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.Safe cooling requires removing heat from food quickly enough to prevent microbial growth. The Food Code provision for cooling provides for cooling from 135 F to 41 F.in 6 hours, with cooling from 135 F to 70 F in 2 hours.The initial 2-hour cool is a critical element of this cooling process. Conversely, if cooling from 135 F to 41 F.is achieved in 6 hours, but the initial cooling to 70 F took 3 hours, the food safety hazards may not be adequately controlled.

During a review of the facility's policy and procedure (P&P) titled, Food Handling Guidelines (HACCP), dated 01/2025, the P&P indicated, Cooling of potentially hazardous cooked foods: Food shall be cooled from 135F to 70F as measured at its center within two hours from 70F to 41F within an additional four hours for a total cooling time of six hours or less. Use the Cooling Log form .to document the temperature of the food at the following times: when placed in cooling equipment, and then at 2 hours and 6 hours after placing in cooling equipment.

During a concurrent interview and record review on 01/07/25 at 3:19 p.m. with DDS and Sous Chef (SC), the Cool Down Log was reviewed. DDS verified there were no documented temperatures of the cool down process for the macaroni pasta, and verified he observed the temperature of the pasta to be 74 degrees F in

the middle of the container, once stirred [cooler part on top was stirred in] the temperature reached 67.8 degrees F, almost five hours after the initial cool down process. DDS was unable to state whether the food was safe to serve to residents. DDS acknowledged staff did not follow the facility's policy and procedure titled Food Handling Guidelines (HACCP) for the cooling down of the macaroni pasta.

2. During an interview on 01/07/25 at 10:51 a.m. with Director of Dining Services (DDS), DDS stated ice obtained from an ice machine located in a pantry adjacent to nursing station 1 was used in the dining room located at the health center (SNF) for residents.

During an interview on 01/09/25 at 10:06 a.m., with LN 1 at nursing station one, LN 1 stated, the ice machine

in the pantry was used for residents water pitchers to provide ice water for hydration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 During a concurrent observation and interview on 01/09/25 at 10:14 a.m., with Maintenance Supervisor (MS)

in the pantry room adjacent to nursing station one, white residue buildup was observed on the ice and water Level of Harm - Minimal harm or dispenser chutes. MS stated housekeeping cleans the external components of the ice machine daily and an potential for actual harm outside vendor cleans the internal components of the ice making apparatus bi-annually. MS stated the white residue was white stuff from water hardness that is building up. Machine is probably due for service soon. Residents Affected - Many

During a concurrent observation and interview on 01/09/25 at 10:21 a.m. with Lead Custodian of housekeeping (LC) in the nurse's station pantry room, LC observed white colored substance along the inside rim of the ice dispenser chute and water dispenser chute. LC stated housekeeping staff wash the ice and water dispenser chutes every day with dish soap and water. LC demonstrated the ice machine cleaning by removing the drip tray and twisted the ice and water dispenser chutes to remove them. Large, thick, amounts of white build up with blackish/brownish colored substance was observed at the location where the water/ice dispenser chutes are twisted into place. LC stated that was residue buildup and housekeeping does not clean those areas.

During a concurrent observation and interview on 01/09/25 at 10:45 a.m. with DDS and MS in the nurse's station pantry room, DDS observed the ice-machine with thick build-up of white and blackish/brownish colored substance where the ice and water dispenser chutes get secured in place. DDS stated it looked like hard water deposits and without swabbing and culturing the area, the dark spots look like mold. DDS acknowledged the dispenser chutes did not look sanitary. DDS and MS verified that neither kitchen staff nor maintenance staff had a role in cleaning of the ice-machine located in the nurse's station pantry room.

During review of the ice-machine's manufacturer's guidelines (MG), dated April 2015, for the specific ice-machine located in the nurse's station pantry room, the MG indicated, Scotsman Ice Systems Service manual for Meridien Ice Maker dispenser models HID32, HID525, and HID540 .Frequency: Recommended minimum time between cleanings is 6 months .More frequent cleanings may be required based on the mineral content of the water, run time and potential airborne contamination.

During a review of the facility's P&P titled, Section: Sanitation and Infection Prevention/Control; Subject: Area and Equipment Cleaning, dated 1/25, the P&P indicated, Policies: The facility's Maintenance Department is scheduled to clean equipment that requires special training and equipment, such as the ice maker .

During a review FDA Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . carbonated beverage dispenser nozzles, beverage dispensing circuits or lines . water vending equipment, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

During review of FDA Food Code (FDAFC), dated 2022, FDAFC indicated, Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

During a review of FDAFCA, dated 2022, FDAFCA indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic [capable of causing disease] microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 3a. During a concurrent observation and interview on 01/07/25 at 09:39 a.m., with DDS in the dry food storage area, a kitchen staff titled [NAME] (PO) was observed sweeping. There was an extensive quantity of Level of Harm - Minimal harm or debris observed on the floor behind, and under, metal racks. PO stated the dry food storage room was to be potential for actual harm swept and mopped one time a day. PO stated there was not a log or requirement for him to sign or initial anywhere after he completed the task. Residents Affected - Many

During a concurrent interview and record review on 01/07/25 at 03:37 p.m. with DDS in the kitchen, DDS reviewed the Master Cleaning Schedule, dated 1/5/25, that indicated the floors were to be cleaned on Monday (1/6/25) and on Friday (1/10/25) with a staff initial once done. DDS stated the cleaning of the floor task was missed on 1/6/25 as there was no staff initial.

During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Prevention/Control: Area and Equipment Cleaning, dated 1/25, the P&P indicated, Managers/Supervisory Personnel assigns weekly and special cleaning to be completed each day.

3b. During a concurrent observation and interview on 01/08/25 at 11:11 a.m., with DDS in the kitchen near

the stove range, observed a floor sink (drain), and the floor located by the floor sink, with buildup of black grime and dried food debris. DDS stated it was not sanitary.

During a review of the Master Cleaning Schedule (MCS), dated 1/5/25, the MCS indicated the Drains were to be cleaned on 1/5/25 and on 1/7/25, the initial column for both days was blank.

During a review of the facility's P&P titled, Cleaning of food and nonfood contact surfaces, dated 1/25, the P&P indicated, Nonfood contact surfaces of equipment, such as .floor drains .shall be cleaned as often as is necessary.

3c. During a concurrent observation and interview on 01/08/25 at 11:14 a.m., with DDS in the kitchen, clean food preparation equipment, such as pots, food holding pans, pitchers were stored directly on shelving that had a buildup of black grime. In addition, there was a worn and discolored pitcher, and a pan with deep scratches that was no longer a smooth cleanable surface. DDS stated the clean dishes were not stored in a sanitary manner. DDS verified some of the foodservice equipment needed to be replaced.

During a review of the facility's P&P titled, Food and Supply Storage, dated 1/25, the P&P indicated, Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

During a review of the facility's P&P titled, Cleaning of food and nonfood contact surfaces, dated 1/25, the P&P indicated, Discard any food contact surfaces with chips, nicks or broken pieces, such as .pans, skillets . which cannot be cleaned properly.

4. During a concurrent observation and interview on 01/07/25 at 09:39 a.m., with DDS inside the walk-in refrigerator, there was a container of cooked spaghetti/linguini noodles on the shelf, undated. DDS stated it should have been dated.

During a review of facility P&P titled Food and Supply Storage, dated 01/2025, the P&P indicated, Cover, label and date unused portions and open packages.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 055733 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055733 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valle Verde Health Facility 900 Calle DE Los Amigos Santa Barbara, CA 93105

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 5. During a concurrent observation and interview on 01/08/25 at 4:05 p.m., with the dishwasher (DW) in the dish machine room, a large clear plastic container was observed located on the floor underneath leaking Level of Harm - Minimal harm or pipes to catch the water. The container was significantly full of water from the leaking pipe and the sides of potential for actual harm the container was extensively covered with a white colored substance. Concurrently, a red bucket was observed located on the floor underneath a leaking pipe located near the 3-compartment sink area. The red Residents Affected - Many bucket was observed to be nearly half -way full of cloudy appearing water from the leaking pipes. DW stated that both sinks, located in the dish machine room and in the 3-compartment sink room, were leaking water.

During an interview on 01/10/25 at 11:26 a.m., with DDS in his office, DDS stated he first became aware of

the leak located in the dish machine room on 1/8/25, and he placed a work order. DDS stated he was unaware of a leaking pipe near the 3-compartment sink and had not placed a work order for that.

During a review of the Work Order (WO), dated 1/8/25 5:13 p.m., the WO indicated, Location: Kitchen, Description of issue: Survey:Water leaking from pipe under dish machine, Details: Surveyors pointed out leak .

During review of FDA Food Code (FDAFC), dated 2022, the FDAFC indicated, A plumbing system shall be: (A) Repaired according to law and (B) Maintained in good repair.

During a review of FDA Food Code (FDAFC), dated 2022, the FDAFC indicated, Physical facilities shall be maintained in good repair.

6. During an observation on 01/07/25 at 09:39 a.m. in the dry food storage room, there were three unenclosed vermin traps with exposed, uncovered, bait located underneath shelving that stored dried food ingredients and dry, covered food.

During an interview on 1/10/25 at 2:45 p.m. with DDS, DDS stated the facility's contracted commercial pest control vendor placed the traps there, and not kitchen staff.

During a review of the facility's P&P titled, Pest Control, dated 1/25, the P&P indicated, Only commercial pest control operators may apply pesticides and place pest control and monitoring devices, including traps and bait, within the foodservice operation .Procedures: To avoid possible chemical poisoning or insect contamination, do not use or store solid poisons, strips, etc., over food preparation areas, or within 12 feet of exposed food and/or food-contact surfaces.

During a review of FDA Food Code (FDAFC), dated 2022, FDAFC indicated, Rodent bait shall be contained

in a covered, tamper-resistant bait station.

During a review of FDA Food Code Annex (FDAFCA), dated 2022, FDAFCA indicated, Open bait stations may result in the spillage of the poison being used. Also, it is easier for pests to transport the potentially toxic bait throughout the establishment. Consequently, the bait may end up on food-contact surfaces and ultimately in the food being prepared or served.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 055733