Arroyo Grande Care Center

In the surveyor’s words

From the most serious findings on record at Arroyo Grande Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF755Aug 12, 2021

  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… […]

• No harm, potential for more than minimal, widespreadF812Aug 12, 2021

  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: 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. […]

• No harm, potential for more than minimal, patternF803Aug 12, 2021

  Based on observation, interview, and record review, the facility failed to ensure the menu was followed for: 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. […]

• No harm, potential for more than minimal, isolatedF761Jul 24, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF803Jul 24, 2025

  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. […]