Health inspection·August 12, 2021

F 0700 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 8/12/21, starting at 9:11 a.m., with a director of nursing (DON), the DON reviewed the electronic health records (eHR) of Residents 35, 41, 54, 61, and 62 and stated there was no documentation of alternatives that were attempted prior to the use of the bed rails. During a review of Resident 35's electronic health records (eHR), the: Residents Affected - Few 1) Face Sheet (FS) a document that gives a resident's pertinent information at a quick glance), indicated, Resident 35 was admitted on [DATE] at 4:30 p.m., age [AGE], admitting diagnoses included, difficulty walking, fractured left femur (upper leg), and a history of falling. 2) Compass Health Verification Of Informed Consent for Use of Side Rails (Consent), dated 6/18/21, at 3:21 p.m., indicated Resident 35 or their representative consented to using bedrails. 3) Side-Rail Use Evaluation Form (Eval), dated 06/18/21, at 3:24 p.m., indicated, on 6/21/21 the interdisciplinary team (IDT) a team of different healthcare disciplines working together to plan a resident's care) recommended alternative interventions of low bed, call light within reach, and answering call light promptly. During a review of Resident 41's eHR, the: 1) FS, indicated, Resident 41 was admitted on [DATE] at 12:36 p.m., age [AGE], admitting diagnoses included, fractured left femur and history of falling. 2) Consent, dated 06/13/21, at 11:02 a.m., indicated Resident 41 or their representative consented to using bedrails. 3) Eval, dated 6/13/21, at 11:06 a.m., indicated, on 6/14/21 and 6/16/21 the IDT recommended alternative interventions of low bed, call light within reach, and answering call lights/alarms promptly. During a review of Resident 54's eHR, the: 1) FS, indicated, Resident 54 was admitted on [DATE] at 1:50 p.m., age [AGE], admitting diagnoses included, Parkinson's disease (affects cells in the brain that controls movement), history of falling, dementia (impaired ability to remember, think, or make decisions), and Schizoaffective disorder (chronic mental health condition with symptoms such as hallucinations or delusions). 2) Consent, dated 7/9/21, at 1:02 p.m., indicated Resident 54 or their representative consented to using bedrails. 3) Eval, dated 7/9/21, at 1:32 p.m., indicated, on 7/9/21, 7/11/21, and 7/12/21 the IDT recommended alternative interventions of low bed, bed alarm, call light within reach, answering call light/alarms promptly, and pad alarm in wheelchair. During a review of Resident 61's eHR, the: 1) FS, indicated, Resident 61 was admitted on [DATE] at 1:45 p.m., age [AGE], admitting diagnoses included, right fibula (lower leg) fracture, history of falling, and ataxia (damage to the brain causing poor coordination). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm 2) Consent, dated 7/15/21, at 1:40 p.m., indicated Resident 61 or their representative consented to using bedrails. 3) Eval, dated 7/15/21 and 7/16/21, at 8:49 a.m., indicated, on 7/15/21 and 7/16/21 the IDT recommended no alternative interventions. Residents Affected - Few During a review of Resident 62's eHR, the: 1) FS, indicated, Resident 62 was admitted on [DATE] at 2:30 p.m., age [AGE], admitting diagnosies included, encephalopathy (a disease that affects the function or structure of the brain) and muscle weakness. 2) Consent, dated 7/16/21, at 12:40 p.m., indicated Resident 62 or their representative consented to using bedrails. 3) Eval, dated 7/16/21, at 12:51 p.m., indicated, on 7/19/21 the IDT recommended no alternative interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure: 1. Expired medications were not stored and available for staff use, in two of two first aid kits, and in one of two treatment carts. These failures had the potential for unsafe and ineffective medication administration that can cause harm to the residents. 2. A licensed nurse followed the facility's policy and procedures (P&P) on medication administration. Findings: 1. During a concurrent interview, and inspection of the facility's two Disaster Kits (D-Kit), on 8/9/21 at 9:45 a.m., with Assistant Director of Nursing (ADON), items observed in a D-Kit, included, a heavy-duty extension cord, flashlight, floor plans, a typed list of area hospitals and nursing homes, a First Aid Kit (FA-Kit) with manual, and other supplies. The two FA-Kits, one in each D-Kit, had a stamped expiration date of 2/18. The labels on the FA-Kits indicated, the kits contained items such as gauze dressing pads, tweezers, scissors, adhesive bandages, tape, and other supplies. In addition, the labels also indicated, the kits contained oral and topical (to apply directly to a body part) medications. According to the manufacturer's product information included on the labels, This kit may contain dated items. Please check before use. Further inspection of the contents of the FA-Kits revealed, expired medications: a total of 12 (six in each kit) packets of First Aid/burn cream 0.9 grams (expired 6/18), a total of 12 (six in each kit) BZK (Benzalkonium Chloride - alcohol-free, non-sting wipes used to disinfect the skin) antiseptic towelettes (expired 5/18), a total of 12 (six in each kit) insect sting relief pads (expired 4/20), a total of 12 (six in each kit) packets of antibiotic ointment (expired 5/18), a total of two (one in each kit) 4 oz. (ounce) containers of eyewash solution (expired 6/18), and a total of 20 (10 in each kit) two-pack Aspirin (medication used to reduce pain, fever, or inflammation) packets (expired 6/18). During an interview, on 8/9/21 at 10:18 a.m., with the Central Supply Supervisor (CSS), the CSS stated, a central supply staff conducts the weekly audit of the facility's D-Kits. The CSS further stated, I never really checked for the (first aid kit's) expiration date. During an interview, on 8/9/21, at 11:48 a.m., with the Director of Nursing (DON), the DON stated, There should be a First Aid Kit available for emergency use, at all times, in the facility. The DON also stated, they were the only available FA-Kits in the facility. During a concurrent interview, and inspection with the ADON, on 8/9/21 at 11:40 a.m., the Treatment Cart (a wheeled, storage unit carrying supplies, such as dressings, ointments, creams, bandages, etc., used for treatment procedures) was inspected at the facility's Nurse Station 2. The following expired medications were found inside the cart: two tubes of Skin Integrity Hydrogel (used to treat and prevent diaper rash, and minor skin irritations, and ideal for cleaning wounds that helps create a moist, wound environment), that expired 1/21, two tubes of Bacitracin ointment (an antibiotic used to prevent infection in minor cuts, scrapes, and burns), that expired 6/21, and three individual packs of Colactive Plus Ag Collagen Dressing (an advanced wound dressing that facilitates natural wound healing), that expired 6/21. The ADON stated, The nurse assigned with the cart (referring to the treatment cart) for that shift is ultimately responsible in checking that supplies he/she uses are not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 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 0755 expired. The ADON confirmed the medications found in the treatment cart were expired. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedures (P&P), titled, Storage of Medications, undated, the P&P indicated, in part, Medications and biologicals are stored properly, following the manufacturer or provider pharmacist's recommendations, to maintain their integrity and to support safe, effective drug administration. The P&P indicated further, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. Residents Affected - Many 2. Prior to the start of the facility's 9 a.m. medication pass on 8/10/21, Medication Nurse 1 (MN1) began passing 9 a.m. medications to unsampled Resident 1 at 7:39 a.m., on the morning of 08/10/2021. Interview with MN 1, MN1 stated, that she would commonly start her 9 a.m. medication pass at 8 a.m., however she would start early if a resident had asked for a PRN (as needed dose of a medication). MN1 passed the following medications to unsampled Resident 1, between 7:39 am and 7:50 am on the morning of 08/10/2021: Multivitamins, MiraLAX (laxative) 17 grams, Prednisone (steroid) 40 mg (milligrams), Metoprolol (blood pressure) 12.5 mg, Telmisartan (blood pressure) 20 mg, Duloxetine (antidepressant) 20 mg, Myrbetriq (bladder) 50 mg, ASA ([aspirin]blood thinner) 81 mg, Preformist (bronchodilator) 20 mcg (micrograms) /2 ml (milliliter) vial. During a concurrent interview and review of the facility's policy and procedure (P&P) titled, Nursing Care Center Pharmacy Policies and Procedures, undated, on 8/10/21 at 8 a.m., the P&P indicated: Medications are administered within 60 minutes of scheduled time . In addition, the P&P indicated, all routine 9 a.m. medications are to be administered between the hours of 8 a.m. and 10 a.m., The DON confirmed the policy's medication administration times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 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 0758 Level of Harm - Minimal harm or potential for actual harm 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. The facility failed to ensure that one resident was free from unnecessary drugs. Residents Affected - Few Resident #15 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on resident interview, clinical record review, and review of the drug manufacturer's specifications, the facility failed to ensure that, each resident's drug regimen was free from unnecessary drugs, including medications used for an excessive duration. This medication used in this manner, could have prevented this resident from reaching her highest functional capacity. Findings: Review of the clinical record for sampled Resident 15 on 8/12/2021 at 10:15 am with the Director of Nurses (DON), confirmed that this resident had been taking Zolpidem (Ambien) a sleeping medication 5 mg as needed during her hour of sleep. This medication was ordered by the resident's physician on 6/11/2021 (one day after the resident's admission to the facility). Interview with Resident 15 on 8/12/2021 at 9:20 am Resident 15 stated that she was unable to sleep at night because of the light in her eyes from the hallway and the room light above her bed. The Resident's inability to sleep because of the light in her eyes had not been care planned or documented into the resident's care plan or medical record. Resident 15 also indicated that she did not request for her sleeping pill at night, but she indicated that nursing staff were bringing this medication to her even though she had not requested this sleeping medication. This resident received the first dose of Zolpidem 5mg on the evening of 6/12/2021 and she only received 6 more doses for the remainder of 6/2021. For the month of 7/2021, Resident 15 received this sleeping medication 29 times during the month of 7/2021, and between 8/1/2021 and 8/11/2021 this resident received this medication 9 times. Review of the drug manufacturer's (Sanofi-Aventis) package insert reads: Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia should be initiated only after a careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. Worsening of insomnia or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. Such findings have emerged during treatment with sedative/hypnotic drugs, including zolpidem. Interview with the DON on 8/12/2021 at 10:15 am confirmed that neither a physician nor a psychiatrist had evaluated this resident for a psychiatric or medical illness related to this resident's insomnia to resolve within the 7-10 days for which this resident received treatment. This resident's medication use, clearly exceeded the manufacturer's 7-10 days of treatment, leading to an excessive duration for the use of this medication for Resident 15. Interview with the DON on 08/12/2021 at 10:15 am revealed that the DON was unaware at the time of our discussion that Resident 15 had any trouble sleeping. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 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 Based on observation, interview, and record review, the facility failed to ensure the menu was followed for: Residents Affected - Some 1) Two of two residents (Residents 4 and 36) on the small portion minced and moist diet, and 2) Two of two residents (Residents 6 and 16) on the small portion soft and bite sized diets for the lunch meal on 8/9/21. This failure had the potential to result in not meeting the nutritional needs of the residents and further compromising their medical status. Findings: During a review of the lunch menu for day 23 (8/9/21), the menu indicated, for MM5 (minced and moist) diet: three ounces chicken baked, #8 scoop (1/2 cup or 4 ounces) MM pasta and sauce, #8 scoop MM zucchini. The lunch menu indicated, SB6 SM (small and bite sized, small portion) chicken baked - 2 ounces, SB pasta and sauce #10 scoop (2.75 ounces), #8 scoop SB zucchini. There was no menu column that indicated what the small portion, minced and moist diet should receive. During an observation on 8/9/21, at 11:57 a.m, of the lunch meal service, the following was observed, a #16 scoop (1/4 cup or 2 ounces) and a #8 scoop in the pasta and couscous, 2 ounce ladle in chicken SB and #16 scoop for MM chicken, and 4 ounces ladle in the zucchini pan. The Diet Aide called out the diet that was written on the tray tickets to the cook and the cook dished up food onto the plates. Each tray ticket indicated, the food items for the meal and the portion of the diet. The Diet aide did not call out the portion sizes for each diet, just the type of diet. Further observation on 8/9/21, at 11:57 a.m., of the lunch meal service, Kitchen Staff (KS) 3 was observed using a small 2 ounce meat and #16 starch scoop for all small diets. KS 3 served 1. Residents 36 and Resident 4, #16 scoop MM5 pasta and 2 ounces for chicken; and 2. Residents 6 and 16, #16 scoop for SB pasta and 2 ounces for SB chicken. Review of Residents 4, 36, 6, and 16 tray tickets, indicated, both MM5 and SB6 small portions were to receive #10 scoop of pasta and 2 ounces chicken. During an interview on 8/09/21 at 12:31 p.m., after the lunch meal service was completed, with KS 3, KS 3 confirmed 2 ounces of chicken meat for small portions and #16 scoop (1/4 cup) for starch either pasta or couscous. During an interview on 8/11/21, at 9:30 a.m., with the Registered Dietitian (RD), the RD stated, they have been working with the company that puts out the menu and tray card system since they have implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) diets (MM and SB diets) as it has been a work in progress. During an interview on 8/11/21 at 10:08 a.m., with the RD, the RD stated, the expectation is to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 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 follow menus and she acknowledged they have some issues with small portions and will need to work on it. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/11/21 at 12:25 p.m., with the RD, the RD state, that maybe they need to look at the system more closely to see if they are able to have the same scoops across the board for all types of small portion diets to make it easier on the cooks. The RD stated, KS 3 had been on vacation and came back to work early due to another cook was sick and she hadn't had a chance to work with her much since her being FT at the facility. The RD stated, there may be an opportunity to review the menu with her. Residents Affected - Some During a review of the facility In-Service dated, 1/21/21, to teach and reinforce personnel the importance of following the menu spreadsheets, the sign-in sheet indicated, KS 3 was present. The In-service indicated the method of evaluation was a paper test. The facility did not provide KS 3's evaluation test from the In-Service. During a review of the facility In-Service dated 3/31/21 with course content to Identify IDDSI diet labels, definition of characteristic of food, physiological rationale, the in-service indicated, the method of evaluation was questions and answers. Review of the content for the In-Service did not indicate the staff was trained on the small portions however, they did receive training on MM and SB diets. Review of the sign in sheet indicated, KS 3 was not in attendance. During an interview on 8/12/21 at 2:33 p.m., with the DON , the DON stated, the facility could not locate a job competency for KS 3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety when: Residents Affected - Many 1) kitchen staff did not have all their hair restrained, and 2) food items were past their best buy date in the reach-in refrigerator. This had the potential for food to be contaminated by hair and the quality of the food may change past the use by date. The census of the facility was 74. Findings: 1. During an observation on 8/09/21, at 10:57 a.m., in the kitchen, Kitchen Staff (KS) 1, was making peanut butter and jelly sandwiches with hair under hat but hair in back not restrained while making sandwiches. During an observation on 8/10/21, at 10:37 a.m., in the kitchen, KS 1 was scooping fruit cocktail with 4 ounce slotted ladle into bowls. KS 1 had a hat on head and hair in back not restrained and sides hair coming out of hat down the side of her face. During an observation on 8/10/21 at 11:53 a.m., in the kitchen, KS 2 had hair out the back of hair restraint and down her back. KS 2 was observed putting away clean equipment then putting food items on trays throughout lunch meal service. During an interview on 8/11/21, at 10:08 a.m., with the Registered Dietitian (RD), the RD stated, the expectation is that all hair should be in hair nets or restrained. The surveyor showed RD pictures of KS 1 and 2, RD confirmed the hair was clearly down her back and not in hair net regarding KS 2. RD stated KS 1 should also have a hair net for the rest of her hair with her hat. The RD acknowledged hair was not restrained. During an interview on 8/11/21 at 11:25 AM, with the RD, the RD stated the policy is vague regarding hair restraints. During a review of the facility policy and procedure (P&P) titled, Food and Nutrition Services - Dress Code Policy, undated, the P&P indicated, employees shall cover hair with appropriate hair hat and/or beard nets as appropriate. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, the Code indicated, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 2. During the initial kitchen tour and concurrent interview, on 8/9/21, starting at 9:00 a.m., with the Kitchen Manager (KM), an observation of a crate of approximately 40-50 cartons (8-ounce (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arroyo Grande Care Center 1212 Farroll Avenue Arroyo Grande, CA 93420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm cartons) of Fat Free milk with a best by date of 8/8/21. The KM stated, they go by the best by date, and it should not be used. KM stated, did not realize this date was yesterday and they will put something on it, so it won't be used. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555619 If continuation sheet Page 10 of 10