F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to appropriately label and store drugs when
three cartons of Med Pass 2.0 fortified nutritional shake were found to be expired in the medication room of
nursing station two.This failure had the potential to result in residents possibly receiving expired and
ineffective medication.During a concurrent observation and interview on [DATE] at 10:12 A.M. with licensed
nurse (LN 3), while checking medications in Station 2 medication room, found three cartons of Med Pass
2.0 fortified nutritional shake, (drink to add additional dietary calories and protein Fortified with vitamins and
minerals), expired. Two expired [DATE] and one expired [DATE]. LN 3 confirmed they are expired and
stated, Those need to go. It's all med nurses responsibility to check them.During a review of the facility's
policy and procedure titled Medication Storage dated [DATE], indicated, . N. Outdated .medications .are
immediately removed from stock, disposed of according to procedures for medication disposal .
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 3
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
07/24/2025
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to follow the nutritional needs of a
residents in accordance with recommended guidelines diet prescription for a renal diet for one of one
resident (Resident 72) when Certified Nurse Assistant (CNA) 4 added salt to the resident's meal. This
failure has the potential of not meeting the nutritional goal of the resident as prescribed diet. During an
observation on 7/22/25 at 7:48 am at the dining room, Resident 72 was observed for her meal intake.
Certified Nurse Assistant (CNA) 4 was overheard offering Resident 72 if she wanted to have salt and
pepper on her meal with the resident responding with a nod. CNA 4 opened the salt packet and sprinkled
salt into resident 72's meal.During a concurrent interview and record review on 7/22/25 at 7:48 am with
CNA 4, the meal ticket of Resident 72 was reviewed. The meal ticket indicated in part, Minced Meat, Renal,
Nectar Thick Large Minces /LS. CNA 4 stated that she reviewed the meal ticket and is aware that it is a
renal diet and states that the LS means low salt that is why she added salt and pepper to the meal.During
an interview on 7/22/25 at 7:55 am with the Registered Dietician (RD) and Dietary Manager (DM), both
stated that LS stands for low sugar and renal diets are not supposed to have no salt added to their
meals.During a review of Policies and Procedures (P&P) titled Diets Available on Menu, the Diets Available
on Menu indicated in part, 1. Diets will be offered as ordered by physician or his/her designee . The
therapeutic diet orders that will be offered are g. Low Sugar (LS), 2. In an effort to individualize therapeutic
orders, secondary diet orders may be offered and can be combined with the main diet order to achieve
desired results: a. No salt packets/No salt on table.
Event ID:
Facility ID:
555619
If continuation sheet
Page 2 of 3
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
07/24/2025
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
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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 safety standards were
followed when an expired milk, brought in by family, was found in the snack refrigerator in nursing station
2.This failure had the potential to cause food- borne illness to a vulnerable resident.During a concurrent
observation and interview on 7/22/2025 at 10:35 A.M., with licensed nurse (LN 2), while checking the snack
refrigerator in Station 2, found an Alta Dena reduced fat milk (brought in by family) was expired on
6/17/2025. LN 2 confirmed the milk was expired and stated, We usually check items brought in by family.
We should check it daily.During a review of the facility's policy and procedure titled, Resource: Food Safety
for Your Loved Ones, dated 2022, indicated in part ., Food or beverages should be labeled and dated to
monitor for food safety: . Foods and beverages that have passed the manufacturer's expiration date will be
discarded.
Event ID:
Facility ID:
555619
If continuation sheet
Page 3 of 3
