Los Banos Post Acute

Inspectors wroteBased on interview and record reviews, the facility failed to ensure a Registered Nurse (RN) provided services for at least 8 consecutive hours a day for eight (5/3/25, 5/10/25, 5/31/25, 6/22/25, 6/24/25, 6/28/25, 7/6/27, 8/3/25) of 90 days sampled. This failure had the potential to result in residents not receiving services required to be provided by an RN . During an interview on 8/6/25 at 3:46 p.m. with the Staff Coordinator (SC), the SC stated no registered nurses (RN)were on working on 5/3/25, 5/10/25, 5/31/25, 6/22/25, 6/24/25, 6/28/25, 7/6/27, 8/3/25. The SC stated she was not responsible for making the schedule for the registered nurses. The SC stated the Director of Nurses (DON) was responsible for the nurse's schedule. During an interview on 8/7/25 at 4:33 p.m. with the DON, the DON stated it was hard to hire an RN. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 58 out of 58 sampled residents had complete nutrition-focused physical exams (NFPE) completed when RD did not follow current standards of practice and the facility's job description titled, Registered Dietitian Nutritionist when she was a part-time remote employee. These failures resulted in incomplete nutrition-focused physical exams and placed residents at risk to not be accurately assessed by identifying nutritional needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively for 55 of 58 residents who received food from the kitchen when DC 1 could not demonstrate recalibration of the kitchen a thermometer according to the facility's policy and procedure (P&P) title, Thermometer Use and Calibration. This failure resulted in the facility to serve and prepare food without the food temperature taken on a calibrated thermometer for residents who obtained food from the kitchen and had the potential to cause foodborne illness (caused by consuming contaminated foods or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices were followed for 55 of 58 sample residents when:1. There was not an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. This failure had the potential to result in residents being exposed to contaminated water which could ultimately result in residents getting food born illness.2. A bin of dried macaroni pasta, an open bag of sausage, an open bag of tortillas and a prepared fruit salad were not labeled with open or used by date.3. The resident refrigerator had food that had been brought into the facility that was not labeled with a resident name, an open or used by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assessment assurance (QAA) committee consisted of the minimum required members when the Medical Director did not attend QAA committee meetings for three consecutive quarters (1/9/25, 4/18/25, and 7/16/25). This failure had the potential to affect the overall medical care provided to all the residents in the facility because the Medical Director was not informed and did not participate in oversite activities that included identifying, analyzing and correcting problems in resident care policies and resident care areas in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to a dignified existence when three of 16 sampled residents (Resident 9, Resident 36, and Resident 43) did not have a dignity covering (a bag or holder designed to conceal and protect the catheter drainage bag [a bag that collects urine from a catheter, a tube inserted into the bladder to drain urine], restoring a sense of privacy and dignity for the user) on their catheter drainage bag. This failure had the potential to result in Resident 9, Resident 36, and Resident 43 experiencing embarrassment or shame due to loss of privacy and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure five out of 16 sampled residents (Resident 4, Resident 8, Resident 11, Resident 28, and Resident 40) were informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed treatment when: 1. Resident 8, Resident 11, Resident 28 and Resident 40 were receiving antipsychotic (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions) and psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications and did not sign an informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) was developed and implemented for five of 16 residents (Resident 8, Resident 15, Resident 28, Resident 40, and Resident 52) when: 1. Resident 8's care plan was not developed and implemented for the administration and monitoring of anti-psychotic medication (a class of medications primarily used to treat psychosis, a mental state where individuals lose touch with reality, experiencing symptoms like hallucinations or delusions). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for two of 15 sampled residents (Resident 4 and 64), when: 1. Resident 4's tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube) flush (water that is pushed through the feeding tube to keep it clean and prevent clogs) bag was not labeled with the date and time it was hung for administration. This failure had the potential to result in Resident 4 receiving an expired tube feeding flush and placed Resident 4 at increased risk of food born illness (any illness resulting from ingesting contaminated/spoiled foods or liquids) and infection. 2. Resident 64 had a 6.2-pound weight gain and the facility did not notify the Registered Dietician (RD) and physician. [...]

Inspectors wroteF687 - Foot Care Based on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice for two of 16 sampled residents (Resident 32 and Resident 48) when Resident 32 and Resident 48 were diabetic (a condition where the body doesn't properly regulate blood sugar levels) and had long, overgrown toenails. This failure had the potential to result in Resident 32 and Resident 48 cutting their skin with their long toenails, leading to poor wound healing, infection, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure four of 16 sampled resident's (Residents 5, 28, 40, and 52) beds were assessed for appropriate bed dimensions, and followed the manufacturers' recommendations and specifications for installing and maintaining the resident's bed side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a raised or lowered position). This failure had the potential to cause entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), serious harm, injury, or death to Residents 5, 28, 40, and 52.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications in one of two surveyed medication carts were labeled and stored according to their Medication Labeling and Storage policy when: one vial of insulin (a hormone that lowers the level of sugar in the blood), and one bottle of melatonin (supplement commonly used to aid in sleep) did not have an open date or expiration date. This failure had the potential for residents to receive expired medication. During a concurrent observation and interview on 8/7/25 at 11:39 a.m. with Licensed Vocational Nurse (LVN) 2 at medication cart two, one vial of insulin and one bottle of melatonin did not have an open date, or an expiration date written on the bottle. LVN 2 stated, there must be an open date on all medication and a visible expiration date to prevent residents from receiving expired medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Waste Disposal policy when two of four garbage bins had their lids open. This failure had the potential to attract insects and rodents which could transmit disease and infection to the residents in the facility. FindingsDuring an observation and interview on 8/5/25 at 2:46 p.m. with the Housekeeping Supervisor (HSK), outside the facility, two trash bins were observed with their lids open. The HSK stated that the trash bins should always be covered to prevent rodents and insects from getting into the trash and then coming into the facility which could make the residents sick. During an interview on 8/5/25 at 3:45 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change of condition assessment (required assessment of cognitive and functional abilities) in resident status for one of eight sampled residents (Resident 9) when Resident 9 was admitted for hospice (end of life care) services. This failure resulted in Resident 9's change of condition to go unreported to direct care staff (all facility staff who directly provide program and/or nursing services to residents), the Registered Nurse, attending physician, family, interdisciplinary team members, and the Director of Nursing (DON) or Assistant Director of Nursing (ADON) and had the potential for Resident 9's care needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal hygiene for one of the seven sampled residents (Resident 48) when all 10 fingernails were long and had black particles underneath. This failure resulted in Resident 48 feeling worried she would injury or scratch herself and she preferred them short.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized, improper, or unlawful use of funds or other property for purposes other than that for which intended) of property and personal belongings when a Certified Nursing Assistant (CNA) 1 used Resident 1's debit card without his consent or permission and charged $376.38. This failure resulted in Resident 1 loss of $376.38 from his bank account.

Inspectors wroteBased on interview and record review, the facility failed to appropriately discharge on e of three sampled residents (Resident 1) when on 8/1/24 Resident 1 went on a leave of absence from the facility at 11:09 am and the facility Administrator (ADM) decided Resident 1's leave was against medical advice (AMA- -when a resident leaves a healthcare facility against medical advice from a physician) and he would be discharged . This failure resulted in Resident 1 being discharged on 8/1/24 without his belongings.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #39) of 1 sampled resident reviewed for physical restraints was free from a physical restraint.

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to ensure the facility assessment was reviewed and updated annually. This deficient practice had the potential to affect all 55 residents who currently resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation of medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when the Certified Nursing Assistants (CNA) did not complete accurate documentation for Resident 1 every two hour repositioning and truing schedule. This failure resulted in inaccurate documentation for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to conduct a facility wide risk assessment specific to the needs of the facility and resident population for 39 of 39 residents when the facility assessment did not include a water management plan. This deficient practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective infection control and prevention program for three of six sampled residents (Resident 25, Resident 32 and Resident 35 when: 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene for three of six sampled residents (Resident 25, Resident 32, and Resident 35) after touching Resident's wheelchair, her clothing, and food containers and proceeded with providing feeding assistance to Resident 32, Resident 35 and Resident 25. This failure had the potential to cross contaminate (the process by which bacteria or other microorganisms [bacterium, virus, or fungus] are unintentionally transferred from one substance or object to another) residents' food and cause infections to residents. 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide and maintain a minimum of at least 80 square feet (Sq. Ft) per resident in eleven resident rooms (Room - Rm. # 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15). This failure resulted in inadequate space for staff to deliver care, insufficient space for resident's personal belongings, wheelchairs and could impact the residents' quality of life or quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food, in accordance with professional standards for food service safety when: 1. An employee's large beverage container, half consumed, was stored on the shelf in the freezer with residents' food. 2. A baking pan full of green Jell-O was stored in the refrigerator uncovered and available for resident consumption. These deficient practices had the potential for food to become contaminated with harmful microorganisms causing foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), placing residents at an increased risk of being exposed to infectious agents.