Other·December 17, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during a RECERTIFICATION survey. Representing the California Department of Public Health by Federal ID: 38641 RN/HFEN and 39818 RN/HFEN. Capacity: 59 Census: 40 Sample: 35 The following Facility Reported Incident (FRI) was investigated during the RECERTIFICATION Survey: FRI CA00583730: Substantiated with deficiency. Refer to F tag 689,726, and 867

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 09/17/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 1 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview and record review, the facility failed to provide reasonable accommodation of residents needs and preferences for one of 35 sampled residents (Resident 2) when Resident 2's call light was not within her reach. This failure had the potential to result in Resident 2 to not be able to call for assistance by using the call light in the event of need or in an emergency. Findings: On 8/21/18 at 7:46 a.m., during an observation in Resident 2's room and concurrent interview, Resident 2 was sitting up in her bed and her call light cord dangled below the bed and not within her reach. Resident 2 stated, "Sometimes I don't get the help I need. I don't even know where my [call light] is. I just have to yell to get help." Resident 2's face sheet (a document with resident profile information) indicated Resident 2 was admitted to the facility on 4/21/17 with diagnoses of muscle weakness, difficulty in walking and history of falling. Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/10/18, indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score of three points out of fifteen points which indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required extensive assistance of two staff members to transfer from one surface to another. On 8/21/18 at 7:48 a.m., during an observation in Resident 2's room and concurrent interview, Licensed Vocational Nurse (LVN) 1 stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 2 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE does not see Resident 2's call light. LVN 1 stated, "Its right here [dangling on the side of the bed] it just slid off the bed." On 8/21/18 at 12:15 p.m., during an interview, the Director of Nursing (DON) stated, "Call lights should always be within reach in case the resident needs something." The facility policy and procedure titled, "Answering Call Lights" dated 10/10, indicated "... The purpose of this procedure is to respond to the resident's requests and needs... General Guidelines... 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident..."

F559 SS=D Choose/Be Notified of Room/Roommate Change CFR(s): 483.10(e)(4)-(6)

F559 09/17/2018 §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. §483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. §483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide written notice before resident's room change for one of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 3 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 35 sampled residents (Resident 2) when: 1. Resident 2 was moved to a different room without providing a written notice which included the reason for the move. 2. The facility failed to notify one of three residents (Resident 32) of a new roommate prior to moving Resident 2 in the room. These failures violated Resident 2's right to receive a written notice prior to the room change and violated Resident 32's right to be informed of a new resident moving in the room. Findings: 1. On 8/23/18 at 11:30 a.m., during an observation in Resident 2's room and concurrent interview, Resident 2 laid in her bed. Resident 2 stated, "[The staff] moved me here in this new room yesterday. I don't know why they moved me. They didn't tell me the reason why they just moved me. I liked it better in my old room. I hope I get to go back in my old room, I really like it there." Resident 2's face sheet (a document with resident profile information) indicated Resident 2 was admitted to the facility on 4/21/17 with diagnoses of muscle weakness, difficulty in walking and history of falling. Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/10/18, indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score of three points out of fifteen points which indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required extensive assistance of two staff members to transfer from one surface to another. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 4 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 2's progress notes dated 8/22/18, indicated "... Resident [2] accusing her roommate ... of stealing her belongings, roommate very upset about it, daughter here, asked [Resident 2] and daughter if she [Resident 2] would like to move out of the room, [Resident 2] said yes, asked [Resident 2] if she would like to move to [another] room ... [Resident 2] agreed, will be moving her [Resident 2] today..." Resident 2's clinical record did not indicate a written notice was provided to Resident 2 or her responsible party prior to moving Resident 2. There was no documentation on how Resident 2 was adjusting to the room move. On 8/24/18 at 8:40 a.m., during an interview, Licensed Vocational Nurse (LVN) 3 stated, "I don't know when they moved [Resident 2]. [The staff] told me she was arguing with one of her roommates." On 8/24/18 at 8:52 a.m., during an interview, Registered Nurse stated, "[Licensed Nurses] chart for one day when residents are moved to a new room." On 8/24/18 at 8:53 a.m., during an interview and concurrent record review, the Director of Nursing (DON) stated, "The SSD [Social Service Director] takes care of the room changes. The DON reviewed Resident 2's clinical record and stated, "I don't see follow up charting on the social service notes that [SSD] charted after [Resident 2] got moved. The [SSD] should have charted a follow up [note] to see how [Resident 2] was doing [with the room move]." On 8/24/18 at 9:06 a.m., during an interview and concurrent record review, the SSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 5 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reviewed Resident 2's progress notes and stated, "I just talked to [Resident 2's daughter] and [both] agreed [to the room move]. I didn't chart [document Resident 2's adjustment to the room move] after that. I did not document after [Resident 2] got moved to a new room. I just spoke to the resident verbally and she told me she didn't like her new room because she missed her old room and the CNA's [Certified Nursing Assistant's]... I should have charted it..." On 8/24/18 at 9:18 a.m. during an interview, LVN 3 stated, "[Licensed Nurses] use to chart when a resident moves to a new room but we haven't been doing that lately. It's [SSD] who does the charting after a resident moves to a new room." On 8/24/18 at 9:34 a.m. during an interview, the DON stated SSD should have documented follow up notes on how the resident was adjusting with the room change. The DON stated, "It's the Social Services Job to follow up and document how she was doing and adjusting. The SSD's job is to make sure residents are supported if there are any changes, assist them if they need help and let the roommates in the room know they have a new roommate coming in." The DON stated, "This is the resident's home. They need to know what is going on or if there are any changes." 2. On 8/24/18 at 9:34 a.m., during an observation in resident 32's room and concurrent interview, Resident 32 was sitting in her wheelchair and stated, "I don't know, I have a new roommate. [The staff] didn't tell me. It would be nice for them to tell me I have a new roommate. I would like to know." Resident 32's MDS dated 8/13/18, indicated a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 6 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE BIMS score of 15 points out of 15 points which indicated Resident 32 was cognitively intact. Resident 32's clinical record did not include documentation of Resident 32 being informed of a new roommate moving into her room. The facility policy and procedure titled, "Transfer, Room to Room" dated 12/16, indicated, "The purpose of this procedure is to provide guidelines for safely transferring residents from one room to another when such transfer has been approved in accordance with facility policies... Preparation... 1. Orient the resident to the transfer in a form and manner that the resident can understand. Provide the resident with information about... b. Who the resident's new roommate, if any, will be... c. Who will be providing the resident's care... 5... take the resident to see his or her new room before the actual move is made... Steps in the Procedure... 8. Introduce the resident to his or her new roommate... Documentation... The following information should be recorded in the resident's medical record... 3. All assessment data obtained during the move, 4. How the resident tolerated the move... Reporting... 2. Report other information in accordance with facility policy and professional standards of practice..." The facility policy and procedure titled, "Resident Rights" dated 12/16, indicated "... Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to... j. be informed about his or her rights and responsibilities..." The facility policy and procedures failed to include resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 7 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE changed.

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 09/10/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 35 sampled residents (Resident 2) was free from physical restraints when Resident 2 had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 8 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE position change alarm (bed alarm- alerting devices intended to monitor a resident's movement that emits an audible loud sound when the resident moves) in place for staff convenience, without a physician's order, no medical justification, without informed consent from Resident 2 or Resident 2's responsible party and without performing pre-restraint assessment or evaluation to determine the need for bed alarm. This failure resulted in Resident 2 to feel irritated when the bed alarm emitted a loud audible sound every time she moved which restricted her freedom of movement. Findings: On 8/21/18 at 7:46 a.m., during an observation in Resident 2's room and concurrent interview, Resident 2 sat on her bed. A clip on bed alarm was noted to be in place and was in the "on" position. Resident 2 pointed at the clip on bed alarm and stated, "This thing, I really don't like it. It makes a lot of noise. Sometimes I want to remove it and throw it. I don't even want to use it." On 8/22/18 at 10:46 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated, "Some residents have bed and chair alarms in the facility. It's the DON [Director of Nursing] who tells [the staff] if the resident needs a bed or chair alarm. The bed and the chair alarm tells us that they are standing up..." On 8/22/18 at 10:47 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated, "The [Interdisciplinary Team (IDT) - a professional group consisting of a nurse, dietitian, social service person, therapist, and physician who meet to plan resident care] discusses if a resident will be put on a bed or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 9 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE chair alarm after a fall then they talk to the MD [physician] to get the order. The alarms prevent the falls. It tells the staff the residents are calling for help and we need to check on the resident on what they are doing, making sure they don't fall." On 8/22/18 at 11:00 a.m., during an interview and concurrent record review, the DON stated, "[The facility does not] have a [physician's order] for all the bed and chair alarms. It's a nursing measure. It doesn't need a [physician's order]. I didn't know that bed and chair alarms are considered restraints... We just thought it was a nursing measure." The DON stated residents at risk for falls or residents with a history of falls were automatically placed with a chair or bed alarms. The DON stated the Director of Staff Development (DSD) had not educated the staff on position change alarms because the DSD was not aware that position change alarms could be consider as a restraint. On 8/22/18 at 11:05 a.m., during an interview, DON reviewed the clinical record for Resident 2 and was unable to find documentation of Resident 2's physician's order for the bed alarm. An informed consent was not obtained from Resident 2 or Resident 2's responsible party. The clinical record did not contain a restraint assessment or evaluation to determine the medical need for Resident 2's bed alarm. On 8/22/18 at 11:19 a.m., during an interview, LVN 1 stated facility staff was not aware that bed and chair alarms could be considered restraints. LVN 1 stated, "The DSD did not conduct any training or in-service with us about the alarms. It's just an automatic thing we do. We put alarms on residents that had fallen or high risk for falls." On 8/22/18 at 11:30 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 10 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observation in Resident 2's room and concurrent interview, Resident 2 sat in her bed. A clip on bed alarm was in place and was in the "on" position. Resident 2 stated, "This thing makes me so mad. It makes a really loud sound every time I move then it wakes everybody up. I don't like it. They did not tell me what it's for but it's irritating me. I feel like I can't move every time it makes a loud sound." Resident 2's face sheet (a document with resident profile information) indicated Resident 2 was admitted to the facility on 4/21/17 with diagnoses of muscle weakness, difficulty in walking and history of falling. Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/10/18, indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score of three points out of fifteen points which indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required extensive assistance of two staff members to transfer from one surface to another. On 8/22/18 at 2:44 p.m., during an interview, CNA 3 stated, "[Resident 2] always had a bed alarm as far as I can remember. Ever since I was hired, she always had that bed alarm." CNA 3 stated she did not know why Resident 2 had a bed alarm in place. CNA 3 stated, "I know [Resident 2] tries to slide her legs [from the bed]. That's why [facility staff] told me she has a bed alarm." CNA 3 stated there was an in service conducted by the DSD on bed alarms and chair alarms and one of the topics of the in service was if a resident had a bed alarm then a chair alarm should also be put in place. CNA 3 stated, "The bed alarm and the chair alarm keeps the resident from standing up on their own. It tells us they are trying to get FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 11 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE up and need help. Our DSD never told [staff] that alarms could be consider a restraint. [Facility staff] thought that's a normal thing to just put an alarm to a resident." The facility policy and procedure titled, "Use of Restraints" dated 2/14, indicated "... Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls... "Physical Restraints" are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body... which restricts freedom of movement... 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention And a restraint is required to... a. treat the medical symptom... c. Help the resident attain the highest level of his/her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be a prerestraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom... 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom)... b. How the restraint will be used to benefit the resident's medical symptom... c. The type of restraint, and period of time for the use of restraint... 10. Orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition required continued treatment..." The facility policy and procedure titled, "Resident Rights" dated 12/16, indicated "... 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 12 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to... d. be free from... physical... restraints not required to treat the resident's symptoms..."

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 09/17/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 13 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 14 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to send a copy of the resident's transfer or discharge notification to the state long term care Ombudsman (resident advocay agency) office for two of 35 sampled residents (Resident 92 and Resident 95) when Resident 92 and Resident 95 were transferred to the General Acute Care Hospital (GACH). These failures resulted in the long term care Ombudsman not being aware of Resident 92 and Resident 95's transfer and discharge circumstances should appeals be filed by the residents or their representative. Findings: The facility document titled, "[name of facility] Admit/Discharge to/From Report... Discharges 3/1/2018 To 8/21/2018" indicated Resident 92 was sent to the acute care hospital on 3/12/18 and Resident 95 was sent to the acute care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 15 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hospital on 8/20/18. On 8/21/18 at 4:14 p.m., during an interview, the Social Service Director (SSD) stated she did not send a copy of the transfer and discharge notification to the state long term care Ombudsman. The SSD stated, "I haven't been doing that. I don't know I had to do that." The SSD stated Resident 92 was transferred to GACH and never came back to the facility. Resident 95 was sent to GACH and the facility did not knew when he would come back. The SSD stated, "I didn't know I had to notify the ombudsman. I haven't done that for residents that went to the acute care, nobody ever told me. I was not aware of the new regulation." On 8/22/18 at 11:00 a.m., during an interview, the Director of Nursing (DON) stated, "I don't know that we were supposed to be notifying the ombudsman if a resident gets transferred to the hospital and does not come back." On 8/24/18 at 7:33 a.m., during an interview, the DON stated, "[The facility] only notify the ombudsman when we discharge a resident. If [residents'] don't come back when we sent them out to the hospital, we discharge them in our system... when they don't come back in the facility, then that is considered a discharge." The facility policy and procedure titled, "Transfer or Discharge Documentation" dated 12/16, indicated "... 7... a. The basis for the transfer or discharge... 1. If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include... c. Resident representative information including contact information and ombudsman..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 16 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F655 Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/24/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 17 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement a person centered baseline care plan within 48 hours of admission for one of 35 sampled residents (Resident 24) when Resident 24 did not have a care plan to identify her dental care needs. This failure resulted in Resident 24's dental care needs going unmet. Findings: Resident 24's face sheet (a document with resident profile information) indicated Resident 2 was admitted to the facility on 9/18/15 and readmitted on 5/10/18. 8/21/18 at 10:01a.m., during an observation and concurrent interview, Resident 24 stated, "I lost my dentures before I came [to the facility] but I want some. I've been here for 3 years and seen the dentist one time and when I did see the dentist medical [Federally funded program] wouldn't pay for it [dentures]. They [facility staff] asked me if I wanted to pay for them and I didn't have $3000." Resident 24's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) assessment dated 7/2/18, indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score of 15 points out of fifteen points which indicated Resident 24 had no cognitive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 18 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE impairment. On 8/23/18 at 3:18 p.m., during a concurrent interview and record review, Social Services Director (SSD) reviewed the clinical record for Resident 24 and was unable to find documentation of a dental needs care plan. SSD stated, "I do not see a dental care plan and there should be one ..." On 8/23/18 at 3:35 p.m., during a concurrent interview and record review, the Minimum Data Set Coordinator (MDSC) assessment (clinical assessment of all residents in a nursing home) stated the dental care plan will be under the nutrition care plan. The MDSC reviewed the clinical record and was unable to find documentation of a dental needs care plan. The MDSC stated, "We should have a dental care plan, but we do not have one." On 8/24/18 at 8:24 a.m., during a concurrent interview and record review, the Director of Nursing, (DON) stated, "There should be a dental care plan on [Resident 24] but there is not one (a care plan)." The facility policy and procedure title, "Care Plans-Baseline," dated 12/2016, indicated "... To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission..."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 09/24/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 19 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for one of 35 sampled residents (Resident 2) when Resident 2 was moved to a new room and a care plan was not revised to ensure Resident 2 tolerated the room move. This failure had the potential to result in Resident 2's psychosocial needs going unmet. Findings: On 8/23/18 at 11:30 a.m., during an observation in Resident 2's room and concurrent interview, Resident 2 laid in her bed. Resident 2 stated, "[The staff] moved me here in this new room yesterday. I don't know FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 20 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE why they moved me. They didn't tell me the reason why they just moved me. I liked it better in my old room. I hope I get to go back in my old room, I really like it there." Resident 2's face sheet (a document with resident profile information) indicated Resident 2 was admitted to the facility on 4/21/17 with diagnoses of muscle weakness, difficulty in walking and history of falling. Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/10/18, indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score of three points out of fifteen points which indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required extensive assistance of two staff members to transfer from one surface to another. Resident 2's progress notes dated 8/22/18, indicated "... Resident [2] accusing her roommate ... of stealing her belongings, roommate very upset about it, daughter here, asked [Resident 2] and daughter if she [Resident 2] would like to move out of the room, [Resident 2] said yes, asked [Resident 2] if she would like to move to [another] room ... [Resident 2] agreed, will be moving her [Resident 2] today..." Resident 2's clinical record did not indicate a written notice was provided to Resident 2 or her responsible party prior to moving Resident 2. There was no documentation on how Resident 2 was adjusting to the room move. On 8/24/18 at 8:40 a.m., during an interview, Licensed Vocational Nurse (LVN) 3 stated, "I don't know when they moved [Resident 2]. [The staff] told me she was arguing with one of her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 21 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE roommates." On 8/24/18 at 8:52 a.m., during an interview, Registered Nurse stated, "[Licensed Nurses] chart for one day when residents are moved to a new room." On 8/24/18 at 8:53 a.m., during an interview and concurrent record review, the Director of Nursing (DON) stated, "The SSD [Social Service Director] takes care of the room changes. The DON reviewed Resident 2's clinical record and stated, "I can't find a care plan for monitoring [Resident 2] [after the] room change. Usually it's under the mood care plan but I don't see one right now. There should be a care plan for the room change to monitor how the resident is doing. I don't know why it's not here." On 8/24/18 at 9:06 a.m., during an interview and concurrent record review, the SSD reviewed Resident 2's progress notes and stated, "I just talked to [Resident 2's daughter] and [both] agreed [to the room move]. I didn't chart [document Resident 2's adjustment to the room move] after that. I did not document after [Resident 2] got moved to a new room. I just spoke to the resident verbally and she told me she didn't like her new room because she missed her old room and the CNA's [Certified Nursing Assistant's]... I should have charted it... I didn't know I was supposed to do a care plan..." On 8/24/18 at 9:18 a.m. during an interview, LVN 3 stated, "[Licensed Nurses] use to chart when a resident moves to a new room but we haven't been doing that lately. It's [SSD] who does the charting after a resident moves to a new room." On 8/24/18 at 9:34 a.m. during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 22 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE DON stated the SSD should have documented follow up notes on how the resident was adjusting with the room change. The DON stated, "It's the Social Services Job to follow up and document how she [Resident 2] was doing and adjusting. The SSD's job is to make sure residents are supported if there are any changes, assist them if they need help and let the roommates in the room know they have a new roommate coming in." The DON stated, "This is the resident's home. They need to know what is going on or if there are any changes." The Administrator provided the facility document titled, "Job Description... Social Service Designee" undated and indicated "... Essential Functions of the Job... 2. Develops the plan of care for social services and updates the plan as changes occur...3. Maintains regular progress and follow-up notes indicating the patient's response to the plan and adjustment to the institutional setting... 5. Coordinates with the ID (Interdisciplinary- a professional group consisting of a nurse, dietitian, social service person, therapist, and physician who meet to plan resident care) team, resident and/or responsible party room changes for residents, 6. Serves as an advocate for resident rights, 7. Making supportive visits to the resident..." The facility policy and procedure titled, "Care Plans Comprehensive Person Centered" dated 12/16, indicated "... A comprehensive, personcentered care plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 23 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/24/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for seven of 35 sampled residents (Resident 7, Resident 2, Resident 17, Resident 13, Resident 25, Resident 4 and Resident 11) when: 1. Resident 7 was administered Aspirin (a medication used to reduce pain, fever and swelling) 81 milligram (mg-a unit of measurement) chewable (crushable) instead of Aspirin 81 mg Enteric Coated (EC- a medication that cannot be crushed) as ordered by the physician. 2. Resident 2, Resident 17, Resident 13, Resident 25, Resident 4 and Resident 11 had position change alarms (bed alarm and chair alarm- alerting devices intended to monitor a resident's movement that emits an audible loud sound when the resident moves) in place without a physician's order and consent per facility policy and procedure. These failures resulted in Resident 7 not getting the correct medication ordered by the physician, Resident 2 to feel irritated when the bed alarm emitted a loud audible sound every time she moved which restricted her movement and placed Resident 17, Resident 13, Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 24 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 25, Resident 4 and Resident 11 at risk of having a bed and chair alarm without medical justification and assessment to determine the need for the device. Findings: 1. On 8/22/18 at 8:03 a.m., during a concurrent observation and interview, Licensed Vocational Nurse (LVN) 2 crushed and administered Aspirin 81 mg chewable and administered the aspirin to Resident 7. LVN 2 stated Resident 7 takes her medications crushed. Resident 7's physician's order dated 2/22/18 indicated "... Aspirin EC 81 mg Give 1 tablet by mouth one time a day for CVA (Cerebrovascular accident- stroke) do not crush..." On 8/22/18 at 8:10 a.m., during a concurrent interview and record review, LVN 2 reviewed Resident 7's medication administration record (MAR) and stated the physician's order indicated Aspirin 81 mg EC. LVN 2 stated, "I gave [Resident 7] the chewable one because she takes her medications crushed." LVN 2 confirmed she did not administer the physician ordered Aspirin 81 mg EC. On 8/22/18 at 8:15 a.m., during a concurrent interview and record review, the Director of Nursing (DON) reviewed Resident 7's physician orders and stated Resident 7 had an order of Aspirin 81 mg EC. The DON stated, "The nurse should give the medication as ordered by the physician. If the resident takes crushed medications then the licensed nurse should clarify (inform the physician) and get a new order from the physician." The facility policy and procedure titled, "Administering Medications" dated 12/12, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 25 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated "Medications shall be administered in a safe and timely manner, and as prescribed... 7. The individual administering the medication must check the label THREE (3) times to verify the... right medication... of administration before giving the medication..." 2a. On 8/21/18 at 11:48 a.m., during observation in the dining room, Resident 17 sat in her wheelchair and had a wheelchair alarm in place. The wheelchair alarm was in the "on" position. Resident 17's clinical record did not indicate a physician's order was obtained prior to placement of the wheelchair alarm and there was no assessment or consent obtained from Resident 17 or her responsible party for the device. 2b. On 8/21/18 at 11:49 a.m., during observation in the dining room, Resident 13 sat in her wheelchair with a wheelchair alarm in place. The wheelchair alarm was in the "on" position. Resident 13's clinical record did not indicate a physician's order was obtained prior to placement of the wheelchair alarm and there was no assessment or consent obtained from Resident 13 or her responsible party for the use of the device. 2c. On 8/21/18 at 11:50 a.m., during observation in the dining room, Resident 25 sat in her wheelchair with a wheelchair alarm in place. The wheelchair alarm was in the "on" position. Resident 25's clinical record did not indicate a physician's order was obtained prior to placement of the wheelchair alarm and there was no assessment or consent obtained from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 26 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 13 or her responsible party for the use of the device. 2d. On 8/21/18 at 11:51 a.m., during observation in the dining room, Resident 4 sat in his wheelchair with a wheelchair alarm in place. The wheelchair alarm was in the "on" position. Resident 4's clinical record did not indicate a physician's order was obtained prior to placement of the wheelchair alarm and there was no assessment or consent obtained from Resident 13 or his responsible party for the use of the devise. 2e. On 8/22/18 at 11:30 am during observation in Resident 11's room, Resident 11 laid in bed with a wheelchair alarm in place. The alarm device was in the "on" position. Resident 11's clinical record did not contain a physician's order was obtained prior to placement of the wheelchair alarm and there was no assessment or consent obtained from Resident 11 or her responsible party for the use of the device. 2f. On 8/21/18 at 7:46 a.m., during an observation in Resident 2's room and concurrent interview, Resident 2 sat on her bed. A clip on bed alarm was noted to be in place and was in the "on" position. Resident 2 pointed at the clip on bed alarm and stated, "This thing, I really don't like it. It makes a lot of noise. Sometimes I want to remove it and throw it. I don't even want to use it." On 8/22/18 at 10:46 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated, "Some residents have bed and chair alarms in the facility. It's the DON [Director of Nursing] who tells [the staff] if the resident needs a bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 27 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or chair alarm. The bed and the chair alarm tells us that they are standing up..." On 8/22/18 at 10:47 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated, "The [Interdisciplinary Team (IDT) - a professional group consisting of a nurse, dietitian, social service person, therapist, and physician who meet to plan resident care] discusses if a resident will be put on a bed or chair alarm after a fall then they talk to the MD [physician] to get the order. The alarms prevent the falls. It tells the staff the residents are calling for help and we need to check on the resident on what they are doing, making sure they don't fall." On 8/22/18 at 11:00 a.m., during an interview and concurrent record review, the DON stated, "[The facility does not] have a [physician's order] for all the bed and chair alarms. It's a nursing measure. It doesn't need a [physician's order]. I didn't know that bed and chair alarms are considered restraints... We just thought it was a nursing measure." The DON stated residents at risk for falls or residents with a history of falls were automatically placed with a chair or bed alarms. The DON stated the Director of Staff Development (DSD) had not educated the staff on position change alarms because the DSD was not aware that position change alarms could be consider as a restraint. On 8/22/18 at 11:05 a.m., during an interview, DON reviewed the clinical record for Resident 2 and was unable to find documentation of Resident 2's physician's order for the bed alarm. An informed consent was not obtained from Resident 2 or Resident 2's responsible party. The clinical record did not contain a restraint assessment or evaluation to determine the medical need for Resident 2's bed alarm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 28 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/22/18 at 11:19 a.m., during an interview, LVN 1 stated facility staff was not aware that bed and chair alarms could be considered restraints. LVN 1 stated, "The DSD did not conduct any training or in-service with us about the alarms. It's just an automatic thing we do. We put alarms on residents that had fallen or high risk for falls." On 8/22/18 at 11:30 a.m., during an observation in Resident 2's room and concurrent interview, Resident 2 sat in her bed. A clip on bed alarm was in place and was in the "on" position. Resident 2 stated, "This thing makes me so mad. It makes a really loud sound every time I move then it wakes everybody up. I don't like it. They did not tell me what it's for but it's irritating me. I feel like I can't move every time it makes a loud sound." Resident 2's face sheet (a document with resident profile information) indicated Resident 2 was admitted to the facility on 4/21/17 with diagnoses of muscle weakness, difficulty in walking and history of falling. Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident care needs) dated 8/10/18, indicated a Brief Interview for Mental Status (BIMS- an assessment of cognitive status) score of three points out of fifteen points which indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 required extensive assistance of two staff members to transfer from one surface to another. On 8/22/18 at 2:44 p.m., during an interview, CNA 3 stated, "[Resident 2] always had a bed alarm as far as I can remember. Ever since I was hired, she always had that bed alarm." CNA 3 stated she did not know why Resident 2 had a bed alarm in place. CNA 3 stated, "I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 29 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE know [Resident 2] tries to slide her legs [from the bed]. That's why [facility staff] told me she has a bed alarm." CNA 3 stated there was an in service conducted by the DSD on bed alarms and chair alarms and one of the topics of the in service was if a resident had a bed alarm then a chair alarm should also be put in place. CNA 3 stated, "The bed alarm and the chair alarm keeps the resident from standing up on their own. It tells us they are trying to get up and need help. Our DSD never told [staff] that alarms could be consider a restraint. [Facility staff] thought that's a normal thing to just put an alarm to a resident." The facility policy and procedure titled, "Use of Restraints" dated 2/14, indicated "... Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls... "Physical Restraints" are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body... which restricts freedom of movement... 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention And a restraint is required to... a. treat the medical symptom... c. Help the resident attain the highest level of his/her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be a prerestraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom... 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 30 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medical symptom)... b. How the restraint will be used to benefit the resident's medical symptom... c. The type of restraint, and period of time for the use of restraint... 10. Orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition required continued treatment..." The facility policy and procedure titled, "Resident Rights" dated 12/16, indicated "... 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to... d. be free from... physical... restraints not required to treat the resident's symptoms..."

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/17/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 35 sampled residents (Resident 1), was free from accidents and injury when Certified Nursing Assistant (CNA) 4 and CNA 5 transferred Resident 1 using a sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) that was past the manufacture's recommended product life. The sling came apart during the transfer causing Resident 1 to fall from a height of two feet and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 31 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE impact the floor with her legs. As a result of this failure, Resident 1 suffered a right femoral (hip) fracture (broken bone). Resident 1 was sent to the General Acute Care Hospital (GACH) where she underwent general anesthesia (medication to render the resident unconscious and pain free during surgery) in preparation for repair of the hip fracture. Resident 1 experienced complications of anesthesia and was determined to be too high risk to proceed with the surgical repair; the surgery was cancelled and Resident 1 spent seven days in the GACH recuperating from the fall. Resident 1 experienced a decline, suffered pain, and became bedbound following the fall and fracture. Findings: Review of Resident 1's clinical record titled, "Admission Record (record containing resident personal information)," indicated Resident 1 was 95 years old and was admitted to the skilled nursing facility (SNF) on 4/16/15 with diagnoses that included dementia (a disorder that affects memory, reasoning, judgement, and ability to communicate) and chronic obstructive pulmonary disease (disease affecting the lungs and the ability to breathe). On 5/8/18 at 9:07 a.m., during an interview, the administrator (ADM) stated on 4/21/18 at 6:45 p.m., CNA 4 and CNA 5 used a mechanical lift with a sling to transfer Resident 1 back to bed from her wheelchair. The ADM stated Resident 1 was suspended above the floor when the sling ripped and Resident 1 fell to the ground and landed right knee first on the floor. The ADM stated the sling broke, or ripped, on both sides without warning; the sling was not visibly frayed or damaged. The ADM stated Resident 1 was sent to the local GACH on 4/21/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 32 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE where it was determined Resident 1 had a broken hip. The ADM stated Resident 1 was returned to the SNF after a seven-day stay at the hospital which included a stay in the intensive care unit and the application of traction to the site (a system of ropes, weights, and pulleys used to immobilize, position, and align a broken bone). The ADM stated Resident 1 was considered a poor surgical risk while at the GACH and did not have surgery to repair the broken hip. On 5/8/18 at 10:25 a.m., during an observation in Resident 1's room, Resident 1 was lying in bed with pillows supporting her right side. Resident 1's eyes were closed and her head tilted slightly with each respiration. Resident 1 did not respond to her name or to questions asked. On 5/14/18 at 11:50 a.m., during a concurrent interview and record review, the ADM stated, "The sling [the sling used on 4/21/18 to transfer Resident 1] had no label, no tracking [number], and the washing instructions had worn down to a sliver ...I cannot honestly put an invoice to each sling." The ADM provided Invoice number 24496556, dated 2/1/17, which she stated was the shipping date for the last slings ordered on 1/27/17 (which would make the newest facility slings one year and two months old when the sling failed on 4/21/18 causing Resident 1 to fall). Review of facility provided manufacturer's publication titled, "[Manufacturer's name] Slings Owner's Manual" dated 2016, indicated, "Limited Warranty ...Anticipated Usable Product Life is based on normal use with proper maintenance, cleaning and storage ...the product may need to be replaced sooner than anticipated in particular situations ...Warranty Period (Parts) 6 months Anticipated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 33 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Usable Product Life 6 months." On 6/22/18 at 10:09 a.m., during an interview, the director of nurses (DON) stated the sling came apart on 4/21/18 causing Resident 1 to fall to the floor and fracture her right hip was used past the manufacturer's guidelines of life expectancy. The DON stated 8/17 was the end of the sling's anticipated usable product life and the facility extended the use of the sling eight to nine months beyond the manufacturer's suggested usable lifetime. Review of Resident 1's GACH clinical record titled, "ED [emergency department] Provider Notes" dated 4/21/18 at 7:46 p.m., indicated, "Patient [Resident 1] presents with trauma: biba [brought in by ambulance] was on [brand name] lift when it ripped, fall 2 feet from the ground. Hip pain: right hip pain s/p [status post or after] fall ...The pain is currently rated at 8/10 [on a zero to ten scale, with zero being no pain and ten being the worst pain imaginable] at this time." Review of Resident 1's GACH clinical record titled "Computed Tomography (CT)" dated 4/21/18, indicated, "FINDINGS ...Displaced [not in alignment] spiral [gradually widening curve] fracture of the proximal [upper half] right femoral diaphysis [shaft]. Approximately 4.6 cm [centimeter, a metric measurement] of override of fracture fragments and one shaft width displacement ...Small amount of hematoma [blood trapped in soft tissue] in the musculature [muscle] surrounding the right femoral fracture." Review of Resident 1's GACH clinical record titled "HOSPITAL COURSE" electronically signed 4/28/18, indicated, " ...Ortho [the branch of medicine dealing with the correction of deformities of bones or muscles] recommended FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 34 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE surgical intervention and patient was taken to operating room. After she was intubated [placement of a flexible plastic tube into the windpipe to maintain an open airway] and given anesthesia -she became profoundly hypotensive [low blood pressure]. Patient was considered very high risk and operation was cancelled. Patient was managed conservatively for pain management and she was placed on traction. Patient slowly improved and her x-ray showed some improvement and no worsening of her fracture. She will [be] managed with pain management only..." Review of the GACH "Inter-Facility Transfer Report" indicated Resident 1 was discharged back to the SNF on 4/28/18. On 6/22/18 at 10:27 a.m., during an interview, the director of staff development (DSD) stated, "[Resident 1] is alone, no family... Since the accident, fall, and fracture, she [Resident 1] requires daily pain medication ...She used to feed herself occasionally; now she is a feeder (requires staff assistance to eat). She doesn't get up at all anymore. She is bedbound. She is not able to go to activities. She used to go to the dining room for all meals, now she's in her room and in bed for meals." The DSD stated Resident 1's quality of life had diminished after the fall. The DSD stated before the sling incident Resident 1 attended activities and although Resident 1 did not actively participate, it presented an opportunity to be up and around other residents. On 6/22/18 at 11:01 a.m., during an onsite interview, the activities director (AD) stated, "[Resident 1] used to get up for meals and activities. Now, we provide one on one activities in her room, like hand massage ...There's a lot of things she misses. She was really active. She loved music, she tapped her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 35 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hands. She used to do peg puzzles and blocks, and she loved that. Now, she's not as mobile. She isn't quite as alert now. Before the accident, she was more animated. Now, she is more subdued, less mobile, less active. She loves the human touch. If you hold her hand, she doesn't want to let go." On 7/31/18 at 5:23 p.m., during a telephone interview, CNA 5 stated she and CNA 4 transferred Resident 1 back to bed after dinner on 4/21/18. CNA 5 stated Resident 1 was transferred from her wheelchair using the sling that was still underneath her from the earlier transfer from the bed to the wheelchair. CNA 5 stated she heard a "rip" during the transfer and Resident 1 was out of the sling and on the floor. CNA 5 stated, "CNA 4 took one step, we heard the rip, and she [Resident 1] was on the floor." CNA 5 stated Resident 1 used to get out of bed for breakfast, lunch and dinner but did not get out of bed after the fall. CNA 5 stated Resident 1 did not complain of pain before the fall but experienced pain after the fall and still had pain. On 8/1/18 at 8:33 a.m., during a telephone interview, the ADM stated Resident 1 fell approximately 25 inches to the floor when the sling ripped on 4/21/18. The ADM stated Resident 1 was getting out of bed today [8/1/18] for the first time since she fell. The Admin stated Resident 1's most recent X-Ray indicated healing, and Resident 1's physician ordered, "Activity as tolerated." Review of Resident 1's X-Ray dated 7/16/18, indicated, " ...Stable healing femoral shaft fracture." Review of Resident 1's physician order, dated 7/19/18, indicated, "Resident may have Activity as tolerated." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 36 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/1/18 at 9:30 a.m., during a telephone interview, CNA 4 stated on 4/21/18 after dinner, she assisted CNA 5 transfer Resident 1 back to bed using a mechanical lift. CNA 4 stated, "The wheelchair and the bed were close together. As soon as we lifted her up, I took a step back, and the sling ripped. It all happened very quickly. She [Resident 1] fell to the floor." CNA 4 stated Resident 1 fell on her side, her right thigh, right hip and right knee hit the floor. CNA 4 stated, "[Resident 1] moaned and her face looked like she was in shock, like she didn't know what happened. Today, she got out of bed for the first time since the fall. The end of April, all of May, June and July she's been confined to bed." Review Resident 1's Physician Orders dated 8/2/18, indicated two pain medication orders. The first order dated revised 4/28/18, indicated "Norco 5-325 milligrams (mg a unit of dosage) (a combination medication containing 5 mg of hydrocodone, a narcotic pain medication for moderate to severe pain and 325 mg of acetaminophen, an over the counter medication for mild to moderate pain) Give 1 tablet every six hours as needed for pain." The second order dated revised 5/1/18, indicated "Morphine Sulfate Solution (liquid narcotic pain medication) 10 mg/5 milliliters (ml a measurement of liquid dosage) Give 2.5 ml by mouth every 4 hours as needed for severe pain." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 37 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F726 Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/24/2018 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure three of 23 Certified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 38 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nursing Assistants (CNA 3, CNA 4 and CNA 5) receive appropriate competencies and skills set training to provide safe use of mechanical lift (a device used to transfer non ambulatory residents) and sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) when CNA 4 and CNA 5 transferred Resident 1 using a sling that was past the manufacture's recommended product life. This failure resulted in the use of a mechanical lift sling past the recommended manufacturer's recommendations and Resident 1's fall with a right femoral (hip) fracture (broken bone). Findings: On 5/8/18 at 9:07 a.m., during an interview, the Administrator (ADM) stated on 4/21/18 at 6:45 p.m., CNA 4 and CNA 5 used a mechanical lift and a sling to transfer Resident 1 back to bed from her wheelchair. The ADM stated Resident 1 was suspended above the floor when the sling ripped and Resident 1 fell to the ground and landed right knee first on the floor. The ADM stated the sling broke, or ripped, on both sides without warning. The sling was not visibly frayed or damaged. The ADM stated Resident 1 was sent to the local GACH on 4/21/18, where it was determined Resident 1 had a broken hip. The ADM stated Resident 1 was returned to the SNF after a seven-day stay at the hospital which included intensive care and traction (a system of ropes, weights, and pulleys used to immobilize, position, and align a broken bone). The ADM stated Resident 1 was considered a poor surgical risk at the GACH and did not have surgery to repair the broken hip. On 8/22/18 at 2:44 p.m., during an interview, CNA 3 stated when she was initially hired [on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 39 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/24/17], the DSD made her watch a video that went over the different areas of the new hire packet. CNA 3 stated, "[DSD] put me on the floor [assigned to resident care duties] with another CNA to show me how [to perform care tasks] get done. The DSD never showed us anything on how to operate the [mechanical lift]. She just showed us the lift and how it looks like. The [DSD] showed us the sling for the [mechanical lift] but not how to use it." CNA 3 stated prior to Resident 1's fall, she did not know who checks the mechanical lifts and sling to determine if they were still in safe condition. On 8/23/18 at 1:58 p.m., during a concurrent interview and record review, the DSD reviewed the facility document titled, "Nurses Aides Orientation Check Off List" dated 1/24/17 and indicated CNA 3 was instructed the proper use of mechanical lift. The DSD was unable to provide documentation of a return demonstration that CNA 3 understood how to safely use a mechanical lift and sling. On 8/23/18 at 2:00 p.m., during a concurrent interview and record review, the DSD reviewed the facility document titled, "Nurses Aides Orientation Check Off List" dated 7/17/17 and indicated CNA 4 was instructed the proper use of a mechanical lift. The DSD was unable to provide documentation of a return demonstration that CNA 4 understood how to safely use a mechanical lift and sling. On 8/23/18 at 2:02 p.m., during a concurrent interview and record review, the DSD reviewed the facility document titled, "Nurses Aides Orientation Check Off List" dated 7/25/16 with an employee signature date of 8/8/16 and indicated CNA 5 was instructed the proper use of a mechanical lift. The DSD was unable to provide documentation of a return demonstration that CNA 5 understood how to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 40 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE safely use a mechanical lift and sling. On 8/23/18 at 3 p.m., during a concurrent interview and record review, the DON stated, "We don't have a policy for annual performance review for the CNA's." The DON provided an untitled and undated facility document and indicated "...9. Performance ... performance evaluation process periodically documents every employee's job performance. Evaluations are conducted at least annually by an employee's supervisor... provide an opportunity for the supervisor and the employee to discuss job problems, goals and training, and to aid communication between the employee and the supervisor..." On 8/24/18 at 7:32 a.m., during an interview, the DON stated, "We don't do an in-service for the [mechanical lift]." The DON stated CNA's only received mechanical lift orientation upon hire. The DON stated the facility did not conduct an ongoing mechanical lift in-service prior to Resident 1's fall.

F730 SS=D Nurse Aide Peform Review-12 hr/yr In-Service F730 CFR(s): 483.35(d)(7) 09/17/2018 §483.35(d)(7) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to complete a performance review of a nurse aide at least every 12 months for three of 23 sampled Certified Nursing Assistants (CNA 3, CNA 4 and CNA 5) when CNA 3, CNA 4 and CNA 5 did not have annual FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 41 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE performance evaluations and skills competencies review. This failure had the potential to result in CNA 3, CNA 4 and CNA 5 to not develop or maintain competencies to provide residents with needed and appropriate care and services. Findings: On 5/8/18 at 9:07 a.m., during an interview, the Administrator (ADM) stated on 4/21/18 at 6:45 p.m., CNA 4 and CNA 5 used a mechanical lift and a sling to transfer Resident 1 back to bed from her wheelchair. The ADM stated Resident 1 was suspended above the floor when the sling ripped and Resident 1 fell to the ground and landed right knee first on the floor. The ADM stated the sling broke, or ripped, on both sides without warning; the sling was not visibly frayed or damaged. The ADM stated Resident 1 was sent to the local GACH on 4/21/18, where it was determined Resident 1 had a broken hip. The ADM stated Resident 1 was returned to the SNF after a seven-day stay at the hospital which included intensive care and traction (a system of ropes, weights, and pulleys used to immobilize, position, and align a broken bone). The ADM stated Resident 1 was considered a poor surgical risk at the GACH and did not have surgery to repair the broken hip. As a result of the fall Resident 1 suffered a right femoral (hip) fracture (broken bone). On 8/22/18 at 2:44 p.m., during an interview, CNA 3 stated, "I haven't gotten an evaluation. [The CNA's] have been asking the DSD [Director of Staff Development]. The last eval [evaluation] I had was July 1, 2017. I haven't had any evaluation after that. I am still waiting and I had been waiting. I told the DSD and she told me she was busy but she was gonna FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 42 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE [going to] get to it." The facility document titled, "[Name of facility] Employee Evaluation indicated CNA 3 was hired on 1/24/17 and her yearly evaluation for 1/2018 was not done. The facility document titled, "[Name of facility] Employee Evaluation indicated CNA 4 was hired on 7/17/17 and her yearly evaluation 7/2018 was not done. The facility document titled, "[Name of facility] Employee Evaluation indicated CNA 5 was hired on 7/25/16 and her yearly evaluation 7/2018 was not done. On 8/23/18 at 1:30 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated, "We go by the CNA's date of hire to do their annual evaluation. It is the DSD's responsibility to do the CNA's annual performance evaluation." On 8/23/18 at 1:58 p.m., during a concurrent interview and record review, the DSD reviewed CNA 3, CNA 4 and CNA 5's employee evaluation records and stated CNA 3's yearly evaluation should have been done on January 2018, CNA 4's yearly evaluation should have been done on July 2018 and CNA 5's yearly evaluation should have been done on July 2018. The DSD stated, "I am late on some of my evaluations. These were not done ..." On 8/23/18 at 2:30 p.m., during an interview, the DON stated the yearly performance evaluation of the CNA's is very important as it tracks the CNA's progress. The DON stated, "[The facility] gives an in service training on the areas [the CNA's] need to improve based on the performance evaluation." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 43 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 8/23/18 at 2:35 p.m., during an interview, CNA 4 stated, "I am due for my annual performance evaluation. I was hired on 7/17/17. I should have gotten my annual evaluation last July [2018]. I am still waiting for the DSD to do it. I don't know why it's not yet done." On 8/23/18 at 2:45 p.m., during an interview, the Administrator stated, "The DSD needs a better system to organize and track if a CNA is due for an annual evaluation." On 8/23/18 at 3 p.m., during a concurrent interview and record review, the DON stated, "We don't have a policy for annual performance review for the CNA's." The DON provided an untitled and undated facility document and indicated "...9. Performance and Pay Review... performance evaluation process periodically documents every employee's job performance. Evaluations are conducted at least annually by an employee's supervisor... provide an opportunity for the supervisor and the employee to discuss job problems, goals and training, and to aid communication between the employee and the supervisor... A written copy of the review is placed in the employee's personnel record..."

F867 SS=F QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 09/24/2018 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have an effective Quality FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 44 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program when: 1. Quality of care and physical environment issues were not identified with appropriate plans of actions developed to correct the identified deficient practice (cross reference F 689, and F 908). 2. Six of seven staff, Certified Nursing Assistant (CNA 7, CNA 8 and CNA 9), Licensed Vocational Nurse (LVN) 3, Registered Nurse (RN) and Housekeeping (HK) were unable to identify the purpose of QAPI or the current facility QAPI projects. These failures resulted in an ineffective QAPI program necessary to improve quality of care provided to residents, maintain essential equipment in safe, operating condition and ensure adequate staff knowledge of the facility QAPI program and QAPI project improvements plans. Findings: 1. On 8/24/18 at 11:28 a.m., during an interview, the Administrator (ADM) stated QAPI projects are identified through resident council meetings, complaints and concerns brought from staff members and department managers. The ADM stated the only current QAPI project the facility is working on is Urinary Tract Infection (UTI- infection of the bladder, urethra and kidney). The ADM did not list any QAPI projects in relation to quality of care issues particularly care provided to residents with a mechanical lift and sling (a hammock like cloth device used to hold the resident during transfer with a mechanical lift) reference F 689. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 45 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ADM stated prior to Resident 1's fall there was no process to check whether the slings used during transfer from the mechanical lift are in good condition. The ADM stated, "Now I know that it is very important to look at the manufacturer's recommendation. The manufacturer's recommendation is very important." The ADM also did not list any QAPI projects in relation to the ice machine and the refrigerator leaking in the kitchen [reference F 908]. The ADM stated, "[Interdisciplinary Team (IDT) - a professional group consisting of a nurse, dietitian, social service person, therapist, and physician who meet to plan resident care) may have talked about it in the stand-up [daily meeting of the department managers]. I knew about the refrigerator leaking and the ice machine leaking but it was my fault. I didn't do anything. I really thought it was just condensation." The ADM stated Maintenance Manager (MM) had a log of the issues and equipment he identified in the facility that needed repair. The ADM stated the facility needs an organized system to track if an issue or equipment needing repair had been resolved. The ADM was informed that MM was unable to provide a policy on how to follow up on maintenance issue repairs and the ADM stated, "The MM should have a policy he follows as a guideline to make sure he follows up on the issues he has identified or the equipment that needs repair." 2. On 8/24/18 at 12: 06 p.m., during an interview, CNA 7 stated, "I don't know what QAPI is. I don't know what projects QAPI is working on. Nobody told me what QAPI is. I don't recall an in-service or training that they told us what QAPI is about." On 8/24/18 at 12:08 p.m., during an interview, CNA 8 stated, "I don't know what QAPI is. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 46 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE have not been told by anyone what QAPI is or what projects [the facility] are working on." On 8/24/18 at 12:10 p.m., during an interview, CNA 9 stated, "I don't know what QAPI is. I don't recall anybody telling me what QAPI is. I don't know what projects QAPI is working on right now." On 8/24/18 at 12:11 p.m., during an interview, LVN 3 stated, "I don't know what QAPI is. What does QAPI stand for? I don't know what QAPI projects the facility is working on right now." On 8/24/18 at 12:12 p.m., during an interview, the RN stated, "I don't know what QAPI is. Is QAPI like a vision or mission of the facility? I'm sorry. I don't know what QAPI is. I don't know what projects QAPI is currently working." On 8/24/18 at 12:14 p.m., during an interview, HK stated, "I don't know what QAPI is. They never told me anything what QAPI is. I don't remember an in-service by the facility on what QAPI is and the projects QAPI is working." On 8/24/18 at 12:20 p.m., during an interview, the Director of Nursing (DON) stated, "[Facility staff] should know what QAPI is. It's in the bulletin board. Now I know, [facility staff] is not reading what is in the bulletin board. I feel bad now that my nurses' don't know what QAPI is." The DON stated QAPI was very important. It talks about issues or concerns in the facility and the areas the facility needs to improve. On 8/24/18 at 12:30 p.m., during an interview, the ADM stated, "[Facility staff] should know what QAPI is. It's in the bulletin board that UTI is what we are focusing." On 8/24/18 at 1:30 p.m., during a concurrent interview and record review, the ADM was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 47 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unable to provide a specific policy regarding QAPI. The ADM provided a facility document titled, "QAPI Written Plan" undated, indicated "... QAPI is a data driven and proactive approach to quality improvement. All members of an organization, including residents, are involved in continuously identifying opportunities for improvement. Gaps in systems are addressed through planned interventions with a goal of improving the overall quality of life and quality of care and services delivered to nursing home residents... The purpose of QAPI in our organization is to take proactive approach to continually improve the way we care for and engage with our residents, nursing staff and all other departments and ancillary services so that we may realize our vision to commitment for providing quality of care and quality of life, resident choice, person directed care and resident transitions for each of our residents... To this, all employees will participate in ongoing QAPI efforts..."

F881 SS=D Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 09/20/2018 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 48 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain an antibiotic stewardship and control program (a system to monitor unnecessary or inappropriate antibiotic use) for one of 35 sampled residents (Resident 34) when Resident 34 was prescribed a prophylactic (medication used to prevent a disease from occurring) antibiotic (ATB- a drug used to treat bacterial infections) without urinary analysis (U/A- a laboratory test of the urine, used to detect and manage a wide range of disorders, such as urinary tract infections) to confirm the presence of an infection prior to ordering ATB medication. This failure had the potential for ATB's to be used when it was not indicated and placed Resident 34 at risk to develop an ATB resistant bacteria. Findings: On 8/24/18 at 10:34 a.m., during an interview, Infection Control Preventionist (ICP) stated Resident 34 was placed on prophylactic ATB without urinalysis. The ICP stated, "The Urologist (A doctor who specializes in the study or treatment of the function and disorders of the urinary system) ordered Antibiotics from 7/19/18 to 8/7/18 with no UA labs done prior to the start of the medication." On 8/24/18 at 1:03 p.m., during an interview, the Director of Nursing (DON) stated the Urologist did not do a UA prior to the start of antibiotics. The DON stated, "We are supposed to do a UA." The DON stated, "The urologist ordered the treatment because [Resident 34] has a history of chronic [frequent] UTI (urinary tract) infections." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 49 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility policy and procedure titled, "Urinary Tract Infections/Bacteriuria-Clinical Protocol," dated 6/14, indicated "... Clinical definitions of UTI are resident-specific and require the aggregation of signs and symptoms, lab [laboratory] data and the clinical judgment of the interdisciplinary team..." The facility policy and procedure titled, "Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome," dated 6/16, indicated "... 3. Appropriate indications for use of antibiotics include...a criteria met for clinical definition of active infection; and b. Pathogen susceptibility [testing performed to determine appropriate ATB use), based on culture and sensitivity [urine analysis test], to antimicrobial (or therapy begun while culture is pending)..."

F908 SS=F Essential Equipment, Safe Operating Condition F908 CFR(s): 483.90(d)(2) 09/20/2018 §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain kitchen equipment in safe operating condition when: 1. The kitchen had a malfunctioning ice machine with water leaking on the kitchen floor. 2. Refrigerator C had an internal water leak and staff placed a water pitcher to collect the water inside the refrigerator where food was being stored. These failures had the potential to result in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 50 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unsafe storage of food which could potentially place residents at risk for food borne illness. Findings: 1. On 8/21/18 at 7:37 a.m., during an observation in the kitchen, refrigerator C had a water pitcher inside with standing water that had been dripping. On 8/22/18 at 10:55 a.m., during a concurrent observation and interview, DC 1 opened refrigerator C and the left upper area of the refrigerator had water dripping and a water pitcher was collecting the water. DC 1 stated, "It's been going on for months." On 8/22/18 at 2:39 p.m., during an interview, DC 1 stated, "We have been putting a water pitcher under the water drip in the refrigerator for months." On 8/23/18 at 1:25 p.m., during a telephone interview, Technician Support (TS) 2 stated, "If it's leaking on the inside of the refrigerator, it is not normal. It should not leak so much you need a water pitcher to catch the water. Something is wrong with the nozzle or something they [facility] need to call tech [technical] support." 2. On 8/21/18 at 7:37 a.m., during an observation in the kitchen and concurrent interview, Dietary Cook (DC) 1 stated the ice machine had been leaking for two days due to condensation (water that collects as droplets on a cold surface when humid air is in contact with it). On 8/22/18 at 10:55 a.m., during an observation in the kitchen and concurrent interview, the ice machine had been leaking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 51 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with water and had multiple mop heads around and under the ice machine. The mop heads were damp and staff were stepping on the damp mop heads. DC 1 stated, "Ice machine is still leaking underneath and is not fixed." On 8/21/18 at 10:08 a.m., during an interview, the Dietary Supervisor (DS) stated the process for reporting a repair to maintenance was to write down the issue or concern on the maintenance log. On 8/21/18 at 11:20 a.m., during an interview, the Maintenance Manager (MM) stated, "Maintenance requests are written down on the log. Staff write it down or verbally tell me when they see me." The MM stated the water pitcher was not supposed to be inside the refrigerator. On 8/22/18 at 2:06 p.m., during a concurrent observation and interview, the MM stated the ice machine had been leaking for at least 3 months. The MM stated, "Someone could slip from the water leaking. I think the drain or something is not working properly." Review of the facility document titled, "Dietary Maintenance Repair Notification Logs" undated, indicated issues with the ice machine and refrigerator dates back since 11/22/17. On 8/23/18 at 1:41 p.m., during a telephone interview, TS 1 stated, "It is not normal for the ice machine to be leaking. That is not normal condensation. It should not be leaking underneath even if it is a 100 degrees [a unit of measurement] in the kitchen." On 8/23/18 at 2:37 p.m., during an interview, the Administrator (ADM) stated, "Maintenance reports came to me. Both machines [ice machine and refrigerator] have been leaking for months but I believed the MM that it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 52 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE condensation. I know the staff could fall and spread germs by stepping on the wet floor from the ice machine." On 8/24/18 at 7:55 a.m., during an interview, the ADM stated, "The standing water in the refrigerator could grow bacteria which is not good for the food and residents could get sick." On 8/24/18 at 9:20 a.m., during an interview, the Registered Dietician (RD) stated," I am aware the refrigerator had been leaking water for months and it was in my reports that go to DS and ADM. I was told by the MM that it was condensation. I told the facility to call an outside contractor because the other refrigerators were not leaking." The RD stated the standing water inside the refrigerator had the potential for mold to grow which could contaminate the food. The RD stated, "I am aware the ice machine is leaking, but I was told by the MM it was condensation. It is in my reports that it needs to be repaired." The RD stated the water on the floor from the ice machine leaking was a safety risk. The RD stated, "Walking in the water is a slip and fall hazard. I told the facility MM to call an outside contractor." The facility document titled, "Consultant Dietitian monthly report" dated 3/21/18, indicated "Condensation build up in (new) refrigerator... Comments/Action taken: Reviewed [with] staff... manager..." 5/23/18, indicated "...Recurring Issues: Maintenance issues, ice machine... condensation buildup in the refrigerator... Comments/Action taken: Reviewed [with] staff and DS... Additional Recommendations/Solutions to Problems Identified... Reviewed [with]... Administrator maintenance issues that needs to be addressed..." 6/20/18, indicated 'Recurring Issues: leak below ice machine, water FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 53 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE condensation/dripping in new refrigerator... Additional Recommendations/Solutions to Problems Identified... Recommended repairs of the recurring issues... fix leak below ice machine, water condensation in walk in..." And 7/25/18, indicated "Recurring issues... condensation issue- new refrigerator and below ice machine... Additional recommendations/Solutions to Problems Identified... Repairs needed... Per Maintenance water leaks under the ice machine and refrigerator are [due to] condensation..." On 8/24/18 at 10:55 a.m., during an interview, the Infection Control Preventionist (ICP) stated she was not aware the refrigerator in the kitchen had a water pitcher inside to collect water that had been dripping from the refrigerator. The ICP stated, "Standing water can spoil food from the moisture and can cause growth of bacteria and fungus." The ICP stated residents food are at risk for contamination and residents can get a gastrointestinal infection and diarrhea. The ICP stated, "Who knows when they are emptying the water pitcher in the refrigerator." The ICP stated she was aware of the ice machine that had been leaking. The ICP stated, "There should not be mop heads on the floor. A lot of water was on the floor last night a puddle which could spread germs. It should not be that way, maintenance was supposed to fix it." On 8/24/18 at 11:28 a.m., during an interview, the DS stated, "I receive the Registered Dietician's consult report and so does the Administrator. I try and follow up and do the recommendations but we kept reporting the refrigerator and ice machine to the maintenance manager and he [maintenance manager] kept saying its condensation." The DS stated the water pitcher with standing water inside the refrigerator could cause cross FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 54 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contamination with the food inside the refrigerator and could cause infection to the residents. The DS stated the ice machine in the kitchen had been leaking with water. The DS stated, "We put mop heads to dry up the water for safety." On 8/24/18 at 12:11 p.m., during an interview, the ADM stated, "I read the RD consult report and I try to do the recommendations but maintenance continued to tell me that it was condensation. None of the other refrigerators were leaking so it's not condensation, I'll take the blame. I should have followed up." On 8/24/18 at 11:28 a.m., during an interview, the ADM stated, "I knew about the refrigerator leaking and the ice machine leaking but it was my fault. I didn't do anything. I really thought it was just condensation." The ADM stated Maintenance Manager (MM) had a log of the issues and equipment he identified in the facility that needed repair. The ADM stated the facility needs an organized system to track if an issue or equipment needing repair had been resolved. The ADM was informed that MM was unable to provide a policy on how to follow up on maintenance issue repairs and the ADM stated, "The MM should have a policy he follows as a guideline to make sure he follows up on the issues he had identified or the equipment that needed repair." The facility policy and procedure titled, "Building Systems," undated, indicated "... Procedure, 2. The facility maintains a Maintenance Request log... the log includes the date, the department employee-making request, description of the request and location of the request. The form provides space to document completion of the request, including the initials of the maintenance personnel, the date and any comments..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 55 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/17/2018 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview during the survey period of 8/21/18 to 8/24/18, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings: During an observation on 8/21/18, the following rooms did not provide the minimum square footage in Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 14 and 15. The residents had a reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. On 8/21/18 at 8:30 a.m., during an interview, Resident 39 stated, "I would like to have a bigger room but it works fine for me. I have no issues on the size of the room." On 8/21/18 at 9 a.m., during an interview, Resident 28 stated, "I am okay. I have been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 56 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE here for quite some time. I have no issues with the size of my room." On 8/21/18 at 10 a.m., during an interview, Resident 25 stated, "I am happy with my room. I have no issues with the size of my room." The residents' bedroom measurements were as follows: Room Number Per Resident Bed Capacity 1 2 3 4 6 7 8 9 10 14 15 4 4 4 4 4 4 4 4 4 4 4 Square Feet 73.62 73.62 73.62 73.62 73.62 73.62 73.62 73.62 73.62 73.62 73.62 Recommend continued room waiver. __________________________________ Health Facilities Evaluator Supervisor Signature & Date Request waiver. ________________________________ Administrator Signature & Date FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7HSZ11 Facility ID: CA040000031 If continuation sheet 57 of 58 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055028 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LOS BANOS POST ACUTE 931 Idaho Ave Los Banos, CA 93635 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 7HSZ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA040000031 (X5) COMPLETE DATE If continuation sheet 58 of 58