Inspection·September 11, 2023

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a proper system was in place to safeguard one of three sampled residents (Resident 1) personal funds when the facility's billing department deposited Resident 1's personal check for rent payment into the facility's bank account. Residents Affected - Few This failure resulted in the misappropriation of Resident 1's personal funds which had the potential to cause emotional distress and anxiety to the resident. Findings: During a review of Resident 1's Face Sheet (FS), dated 8/9/23, the FS indicated in part, Resident 1 was a [AGE] year-old female, who was admitted to the facility on [DATE] with admitting diagnoses including, pneumonia (infection of the lungs) and acute kidney failure (rapid loss of kidney function). The FS also indicated, Resident 1 was discharged from the facility on 10/20/22. During a phone interview on 8/9/23 at 5:25 p.m. with Resident 1, Resident 1 verbalized, asking a facility staff to mail out a personal check as payment for a leased residential property. Resident 1 also verbalized the check was made payable to (name of Resident 1's lease property management) as payment for the month of October 2022. Resident 1 found out the lease property management did not receive the check after receiving a call from them. Resident 1 later confirmed, through her bank, that the check was processed and deposited into an account named after the facility. During an interview on 8/9/23 at 6 p.m. with the Assistant Director of Nursing (ADON), ADON verbalized that the facility's social services department handles all resident requests for mails to be sent out. During a phone interview on 8/9/2 at 6:20 p.m. with an accounts receivable/billing (ARB) staff for the facility, ARB staff recalled, Resident 1's check was endorsed to the facility's billing department and confirmed the check was made payable to Resident 1's lease property management. ARB staff also verbalized, Resident 1's rent check was mistakenly endorsed to be deposited into the facility's bank account thinking it was Resident 1's co-payment for the charges incurred while admitted in the facility. ARB staff further verbalized, that somehow the bank processed the check and the check was cleared. During a review of the facility's policy and procedures (P&P), titled, Protection/Management, Accounting and Records, Notice, and Conveyance of Personal Funds, dated 3/1/18, the P&P indicated in part, (Corporate Name) facilities have established and maintain a system that assures a full, complete, and separate accounting of funds entrusted to (corporate name) facilities on the resident's behalf. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555619 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 09/11/2023 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)