Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Los Banos Post Acute during CMS and state inspections, most recent first.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, as required, on multiple occasions. Staff interviews and record reviews confirmed that on several days, no RN was present to provide necessary services, including care for residents with IV therapy or PICC lines. The DON and Administrator acknowledged difficulties in hiring and retaining RNs, and the facility's own policy requiring daily RN coverage was not followed.
The facility did not employ enough staff with the necessary competencies and skills in the food and nutrition service, including lacking a qualified dietician.
A dietary staff member was found not competent in calibrating food thermometers according to facility policy, as observed during a kitchen inspection. The staff member incorrectly allowed the thermometer stem to touch the bottom of the cup during calibration and was unable to recall proper procedures or recent training. This failure affected the majority of residents receiving food from the kitchen, as confirmed by interviews with the Dietary Service Manager and Registered Dietician.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not ensure the required Medical Director attended three consecutive quarterly QAA committee meetings, as confirmed by sign-in sheets and administrator statements. This resulted in the Medical Director not participating in oversight activities related to resident care policies and ongoing quality improvement projects, such as those addressing falls and UTIs.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
Residents were not fully informed about their health status, care, and treatments, resulting in a lack of understanding and participation in care decisions.
A deficiency was cited when a resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully document or plan for the resident's care requirements.
Two residents experienced deficiencies in care: one received tube feeding flushes from an unlabeled bag, contrary to facility policy and staff expectations, while another had a significant weight gain that was not rechecked or reported to the RD and physician as required. Staff interviews confirmed that these actions did not meet professional standards or facility protocols.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
Surveyors found that a vial of insulin and a bottle of melatonin on a medication cart were not labeled with an open date or expiration date, as required by facility policy. An LVN and the DON both confirmed that all medications should be properly dated to prevent use of expired drugs, and the Pharmaceutical Consultant verified that the policy requires visible expiration dates and dating of multi-dose vials.
Two garbage bins were observed with their lids open, contrary to facility policy requiring all waste containers to be covered to prevent access by rodents and insects. Both the Housekeeping Supervisor and Maintenance Supervisor confirmed that trash should always be covered to prevent disease transmission.
A resident with multiple chronic conditions and newly admitted to hospice care did not receive a required significant change of condition assessment. This omission resulted in the resident's change in status not being communicated to direct care staff, the RN, physician, family, or nursing leadership, contrary to facility policy and job expectations.
A resident with diabetes and moderate cognitive impairment, who required substantial assistance with daily living activities, was found with long, dirty fingernails after staff failed to provide necessary nail care. Staff interviews revealed confusion about responsibilities and a lack of documentation, resulting in the resident not receiving appropriate personal hygiene as outlined in facility policy.
A CNA at a facility used a resident's debit card without consent, resulting in unauthorized charges of $376.38. The resident, who had no cognitive impairment, initially asked the CNA for help with a food delivery order. The CNA saved the card information and made further unauthorized purchases. The facility lacked protocols and training to prevent such incidents, leading to the CNA's termination and law enforcement involvement.
A resident with no cognitive impairment left a facility without a doctor's order, which the Administrator deemed as leaving AMA. Upon return, the resident was informed of discharge and denied medications. The facility lacked a policy requiring a doctor's order for leaving, and the discharge was not documented as per regulations. The resident later signed an AMA form with an incorrect date.
A resident with a history of falls and dementia was found to be using a lap buddy as a physical restraint, contrary to facility policy. The restraint had been in place since the resident's admission, with no attempts to use a less restrictive device or ongoing monitoring. Staff interviews confirmed the restraint's continuous use, and the DON acknowledged that falls were not a valid medical symptom for its use.
The facility did not update its facility-wide assessment annually as required, with the last update recorded nearly two years ago. This lapse potentially affected all 55 residents. Interviews with the DON and NC indicated they were aware of changes in resident acuity and had been working on the assessment since 2023, but it remained incomplete. Both the DON and Administrator expected annual reviews, highlighting a failure to adhere to policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours each day, as required by policy and regulation. Record reviews and staff interviews confirmed that on eight specific days within a 90-day period, there was no RN present to provide services. The Staff Coordinator acknowledged that no RNs were scheduled on those days and clarified that the responsibility for RN scheduling belonged to the Director of Nursing (DON). The DON admitted that maintaining daily RN coverage was difficult and that the absence of an RN could have impacted the quality of care, particularly for residents requiring specialized services such as intravenous (IV) therapy or care for peripherally inserted central catheters (PICC lines). The DON also stated that the facility did not follow its own policy and procedure regarding RN coverage. The Administrator confirmed ongoing challenges in retaining and scheduling RNs, noting that the facility had a revolving roster of RNs and was unable to consistently staff an RN each day. Both the DON and Administrator emphasized the importance of having an RN available daily, especially for residents needing advanced nursing care such as IV therapy. Review of the facility's policy indicated a clear requirement for RN coverage for at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified dates.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. This included not having a qualified dietician as required. The deficiency was identified based on the facility's staffing and qualifications in the food and nutrition department.
Failure to Ensure Competency in Thermometer Calibration in Dietary Services
Penalty
Summary
The facility failed to ensure that a dietary staff member was competent in performing thermometer calibration according to the facility's policy and procedure, affecting 55 of 58 residents who received food from the kitchen. During an observation, the dietary staff member was seen calibrating a thermometer by placing it in a cup of ice water with the stem touching the bottom of the cup, contrary to the facility's policy, which specifies that the stem should not touch the bottom or sides and must remain in the ice water for one minute. The staff member was unable to recall the last in-service training and initially stated it was acceptable for the stem to touch the bottom, later acknowledging this was incorrect and could result in inaccurate temperature readings. Interviews with the Dietary Service Manager and Registered Dietician confirmed that the staff member's method did not comply with the facility's policy and could have led to inaccurate food temperature readings. Both indicated that improper calibration could result in food being served at incorrect temperatures. The Dietary Service Manager and Registered Dietician both stated that the staff member was not competent in this procedure, and the facility's policy was not followed during the calibration process.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
QAA Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the required members, specifically the Medical Director, during its quarterly meetings. Record review and interviews with the Administrator revealed that the Medical Director did not attend three consecutive quarterly QAA committee meetings. Sign-in sheets for the meetings confirmed the absence of the Medical Director or a designee, and the Administrator acknowledged that the Medical Director was not always present at these meetings. Facility documents also indicated that the Medical Director was a required member of the QAA committee, but attendance records did not reflect their participation. The Administrator stated that the QAA committee, which also functioned as the Continuous Quality Improvement (CQI) committee, met regularly to address ongoing issues such as resident falls and urinary tract infections. However, the lack of the Medical Director's attendance meant that they were not informed of or involved in oversight activities, including identifying, analyzing, and correcting problems in resident care policies and areas. The Administrator recognized the importance of the Medical Director's involvement in these meetings, as they are responsible for the physicians and the management of resident care within the facility.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not being able to participate meaningfully in decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not have a clear understanding of their current health status or the treatments they were receiving.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Label Tube Feeding Flush Bag and Notify Clinicians of Significant Weight Gain
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. For one resident with a history of traumatic subarachnoid hemorrhage, schizophrenia, dysphagia, and cognitive impairment, the tube feeding flush bag was observed to be unlabeled with the date and time it was hung. The bag contained approximately 450 ml of fluid remaining in a 1000 ml bag. Staff interviews revealed inconsistent understanding of labeling requirements, with one LVN stating that the flush and feeding were connected as a set and did not require separate labeling, while another LVN and the DON confirmed that the flush bag should have been labeled to ensure timely changes and prevent the use of expired fluids. Facility policy and lesson plans also indicated the need for labeling and dating G-tube supplies. Another resident, admitted with severe protein-calorie malnutrition, COPD, muscle weakness, obstructive sleep apnea, and gastrostomy, experienced a 6.2-pound weight gain over five days. The weight gain was not rechecked for accuracy, and the Registered Dietician (RD) and physician were not notified as required. The Restorative Nursing Assistant (RNA) acknowledged that the weight should have been rechecked and reported, and the Assistant Director of Nursing (ADON) admitted that the physician and RD should have been notified within 24 hours. The DON and RD both confirmed that the weight gain should have prompted immediate notification and further assessment. Facility policy required staff to report significant weight changes to the physician. The failure to label the tube feeding flush bag and to notify the RD and physician of significant weight gain represent lapses in following professional standards and facility protocols. These deficiencies were identified through observation, interviews, and record reviews, and were confirmed by multiple staff members, including the DON and RD.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Label and Date Medications on Medication Cart
Penalty
Summary
Surveyors observed that one medication cart contained a vial of insulin and a bottle of melatonin that were not labeled with an open date or expiration date, contrary to the facility's Medication Labeling and Storage policy. During the observation, an LVN confirmed that all medications are required to have an open date and a visible expiration date to prevent administration of expired medications. The Director of Nursing also stated the expectation that all medications be properly dated. Review of the facility's policy with the Pharmaceutical Consultant confirmed that multi-dose vials must be dated when opened and discarded within 28 days, and that expiration dates must be visible on all medication labels. These findings indicate that the facility failed to ensure medications were labeled and stored according to policy, as required.
Improper Waste Disposal Due to Uncovered Garbage Bins
Penalty
Summary
During an observation outside the facility, two out of four garbage bins were found with their lids open. The Housekeeping Supervisor confirmed that trash bins are required to be covered at all times to prevent rodents and insects from accessing the trash and potentially entering the facility. The Maintenance Supervisor also stated that all trash, both inside and outside the facility, should be covered to prevent the spread of disease. A review of the facility's policy on garbage and rubbish disposal indicated that all waste containers must have tight-fitting lids or covers and be made inaccessible to vermin. The failure to keep the garbage bins covered was directly observed and acknowledged by facility staff.
Failure to Complete Significant Change Assessment Upon Hospice Admission
Penalty
Summary
The facility failed to complete a significant change of condition assessment for one resident when the resident was admitted to hospice care. The resident, who had a history of paraplegia, chronic kidney disease, obstructive and reflux uropathy, adult failure to thrive, and was receiving palliative care, was observed to have hand contractures and required assistance with mobility. Despite a documented order for hospice care and a hospice consult, there was no evidence that a change of condition assessment was completed at the time of the transition to hospice services. Interviews with staff, including an LVN and the DON, confirmed that such an assessment was required by facility policy and should have been conducted immediately upon the resident's change in status. The absence of this assessment meant that the resident's change in condition was not reported to direct care staff, the RN, attending physician, family, interdisciplinary team members, or nursing leadership. Facility policy and job descriptions reviewed indicated that prompt notification and comprehensive assessment are required when a significant change in a resident's condition occurs. The failure to complete and communicate the assessment had the potential to result in unmet care needs for the resident.
Failure to Provide Personal Hygiene and Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes, muscle weakness, and moderate cognitive impairment was found to have long fingernails with black particles underneath, indicating a lack of personal hygiene care. The resident required substantial to maximal assistance with activities of daily living, including upper body dressing, and expressed concern about the risk of injury or scratching herself due to the length of her fingernails. She stated that her fingernails were kept short at home and that she preferred them that way, but the facility had not offered to cut them. Interviews with staff revealed confusion regarding responsibility for nail care, particularly for diabetic residents. Certified Nursing Assistants (CNAs) believed that nurses were responsible for cutting fingernails for diabetic residents, while CNAs were expected to file and clean nails weekly. Both the CNA and a Licensed Vocational Nurse (LVN) acknowledged that the resident's fingernails were dirty and that there was no documentation or log indicating that nail care had been performed as required. The Director of Nursing confirmed that nurses should cut fingernails for diabetic residents and that documentation was lacking. Facility policy required assistance with personal hygiene for residents unable to perform these tasks independently, but this was not followed in the resident's case.
Unauthorized Use of Resident's Debit Card by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property and personal belongings when a Certified Nursing Assistant (CNA) used the resident's debit card without consent, resulting in unauthorized charges totaling $376.38. The resident, who had no cognitive impairment as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), initially asked the CNA to assist with a food delivery order using the CNA's phone and account. However, the CNA saved the resident's debit card information and continued to make unauthorized purchases for personal use. Interviews with facility staff, including the Director of Nurses (DON) and the Activity Director (ACTDIR), revealed that the facility lacked a protocol to prevent such incidents, and no formal education or training was provided to staff regarding the handling of residents' personal funds. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not effectively implemented, as evidenced by the CNA's actions. The CNA was terminated for financial elder abuse, and law enforcement was notified. The resident was eventually reimbursed by the facility after the investigation.
Inappropriate Discharge of Resident Against Medical Advice
Penalty
Summary
The facility failed to appropriately discharge a resident, identified as Resident 1, who left the facility on a leave of absence without a doctor's order. The resident, who had no cognitive impairment as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) assessment, was admitted with conditions including alcoholic cirrhosis, chronic kidney disease, and neuropathy. On the day of the incident, the resident left the facility without signing out or obtaining a doctor's order, which the Administrator deemed as leaving against medical advice (AMA). Upon the resident's return two hours later, the Administrator and Social Service Director informed him that he had been discharged AMA and his belongings had been packed. The resident was not provided with his scheduled medications after leaving the facility, and there was no policy requiring a doctor's order for a resident to leave. The Director of Nurses confirmed that the resident had left the facility before without such an order and questioned what medical advice the resident was going against. The facility's policy on transfer or discharge requires that residents be informed of their right to appeal such decisions, but there was no documentation of a discharge order for the resident. The Social Service Director later had the resident sign an AMA form, which was incorrectly dated. The facility's actions were not in compliance with their own policies or state regulations, which allow for discharge only for specific reasons such as medical necessity or nonpayment.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The resident, who had a medical history of muscle weakness, dementia, repeated falls, difficulty in walking, and dependence on a wheelchair, was observed using a lap buddy as a physical restraint. The facility's policy stated that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully, and should not be used for falls prevention. However, the resident's care plan included the use of a lap buddy due to confusion and falls, and the resident was observed with the lap buddy in place during activities. Interviews with facility staff, including the Director of Nursing (DON), revealed that the lap buddy had been in use since the resident's admission in 2022 due to frequent falls. The DON confirmed that a lesser restrictive device had not been attempted and there was no ongoing monitoring of the physical restraint. Additionally, the DON acknowledged that falls were not a medical symptom justifying the use of a physical restraint. Other staff members, including a CNA and an LVN, confirmed that the lap buddy had been consistently used for the resident, and the Physical Therapist noted that therapy had not been consulted about its use.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was reviewed and updated annually, as required by their policy. The last documented assessment was dated 09/27/2022, indicating that the assessment had not been updated for nearly two years. This oversight had the potential to affect all 55 residents currently residing in the facility. The facility's policy, revised in 10/2018, mandates an annual review and update of the facility assessment to determine the resources necessary to meet the needs of residents during both day-to-day operations and emergencies. Interviews with the Director of Nursing (DON) and Nurse Consultant (NC) revealed that they had been working on updating the facility assessment since 2023, acknowledging that the acuity of the resident population had changed significantly. Despite this, the assessment had not been completed. Both the DON and the Administrator expressed that it was their expectation for the facility assessment to be reviewed annually by the facility management team. However, the delay in updating the assessment suggests a lapse in adhering to the facility's policy and procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Banos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Bethany Skilled Nursing | 2 mi | — | 6 | 0 |
| San Luis Care Center | 20 mi | — | 22 | 0 |
| Grace Home Inc. | 22.7 mi | — | 0 | 0 |
| Anberry Post Acute | 24.1 mi | — | 0 | 0 |
| Anberry Nursing And Rehabilitation Center | 24.3 mi | — | 13 | 0 |
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