Health inspection·March 21, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse for one of sixteen sampled residents (Resident 44) when, Resident 44 was cursed at by Licensed Nurse (LN) 5. This failure had the potential to cause emotional distress and could negatively affect Resident 44's psychosocial well-being. Findings: Review of Resident 44's admission RECORD, indicated Resident 44 was admitted with diagnoses including depression (mental health condition characterized by persistent feelings of sadness) and anxiety (persistent worry) disorders. Review of Resident 44's Minimum Data Set [an assessment tool], dated 2/4/25, indicated Resident 44's Brief Interview for Mental Status score was 13 out of 15 suggesting an intact cognitive functioning (a person's mental processes, including thinking, learning, memory, and reasoning, are functioning normally and without any significant impairment). Review of Resident 44's IDT [Interdisciplinary Team; a group of healthcare professionals] Note, dated 11/13/24, indicated, .On 11/1/2024 [Resident 44] notified SSD [social services director] that he had a complaint of CN [charge nurse; LN 5] who cursed at him a couple of days ago. Resident could notrecall [sic] what the disagreement was about. On the same day CN approached DON [director of nursing] stating she was not getting along with resident and that a couple of days ago resident was following CN and interrupting her conversations she was having with CNA [certified nursing assistant], CN stated she tried to redirect him, and resident was angry and cursing at CN .CN then talked to SSD, asking resident not to bother CN during her shift .On 11/7/2024- A CNA notified DSD [director of staff development] that she had heard CN on 11/1/2024 telling another CNA that she cursed at the resident . During a concurrent observation and interview on 3/20/25, at 1:33 p.m., with Resident 44 in his room, Resident 44 stated he did not have any disagreement with any staff member and stated he felt safe in the facility and had been cared for. Resident 44 stated he did not want to answer any further questions. During a concurrent interview and record review on 3/20/25, at 3:04 p.m., with the Administrator (ADM) and Director of Nursing (DON), Resident 44's [Facility name] FACILITY EVENT REPORT [a detailed report regarding the investigation of the incident], dated 11/8/24, was reviewed. In the section of Page 1 of 7 055662 055662 03/21/2025 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility event report titled, Describe Incident ., indicated, .the Social Services Director .notified the Administrator that [Resident 44] complained this morning about [LN 5] cursing at him a couple of days prior, saying I don't give a fuck at the end of a disagreement [LN 5] and [Resident 44] had. When [name of the SSD] had asked [Resident 44] what the disagreement was about, [Resident 44] could not remember .On the following Thursday afternoon, 11/7/24, a CNA confided to the DSD that she heard [LN 5] on 11/1/24 telling another CNA that she had told [Resident 44] to fuck off . The ADM explained, LN 5 admitted to Certified Nurse Assistant (CNA) 1 that she was working with at the time of the incident that LN 5 had used foul language toward Resident 44. The ADM stated, while LN 5 was explaining the events that had happened, CNA 2 had heard LN 5 admitting what she had done. The ADM further explained no staff had witnessed the disagreement between LN 5 and Resident 44. Further review of the facility event report in the section titled, What is the outcome?, indicated, .Through record review and interviews, it can now be substantiated that [LN 5] used a curse word in her interaction with [Resident 44]. Because of [Resident 44's] past propensity for using that sort of language toward staff and becoming demanding when patience is required, it was believed that there was a disagreement between [Resident 44] and [LN 5] and that [Resident 44] needed a break from [LN 5] providing care for him; however, with other staff reporting [LN 5's] admission to using that language with [Resident 44], though denying it when asked, [LN 5] will not be returning to work at [facility name] . During an interview on 3/21/25, at 10:05 a.m., the DON stated verbal abuse could have a negative effect on residents. The DON stated the residents should feel safe and comfortable in their own home and the facility was their home. The DON further stated verbal abuse could affect the residents psychologically, emotionally, and could manifest physical symptoms such as increased blood pressure and increased breathing. The DON stated residents needed to feel safe in the facility. Review of the facility's policy and procedure titled, Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy and Procedure, revised 3/8/24, indicated, .Each resident has the right to be free from abuse .VERBAL ABUSE: Verbal abuse includes the use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families. This would include use of swear words, making demeaning remarks about a person's appearance or use of such slang expressions such as shut up or be quiet .All residents of [facility name] shall be free from verbal, mental, sexual, physical abuse .Residents must not be subjected to abuse by anyone, including, but not limited to facility staff . 055662 Page 2 of 7 055662 03/21/2025 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs used to control behavior or thought process) for two of five sampled residents (Resident 44 and Resident 52) reviewed for unnecessary medications use when: 1. The physician did not document specific duration for the extended use of the as needed (or PRN) lorazepam (or Ativan, a psychotropic medication for anxiety) beyond 14 days for Resident 52. 2. There was no documented evidence of non-pharmacological interventions (means helping residents with behavioral issue without use of the drugs) for Resident 44 and Resident 52 while taking psychotropic medications for treatment of anxiety. These failures had the potential for unsafe use of psychotropic medications resulting in negative impact or adverse drug effects on Resident 44's and Resident 52's health. Findings: 1. During a concurrent interview with Licensed Vocational Nurse (LN) 3, and record review of Resident 52's medical record, on 3/20/25, at 9:18 AM, LN 3 confirmed Resident 52's order for a routine use in addition to PRN use of lorazepam in the Medication Administration Record (or MAR, a document that listed medication orders for administration) with no end date as follows: Lorazepam Oral Tablet 0.5 MG (Lorazepam); Give 1 tablet by mouth three times a day for Anxiety m/b (manifested by) restlessness, and inability to relax; start date 10/31/2024. Lorazepam oral tablet 0.5 mg (mg is milligram, a unit of measure); give 0.5 mg by mouth every 4 hours as needed for Anxiety R/T (Related To) disease process/SOB (Shortness of Breath) M/B (manifested by) fidgeting, constant repetitive movements; Start date: 8/6/2024. LN 3 confirmed the PRN order for lorazepam had not been evaluated for continuation beyond 14 days after the initial date of order. LN 3 stated the team conference for evaluation of the psychotropic medications were conducted every 3 months and additionally every month the behavior data were documented in the monthly drug summary review for the medical doctor to see and sign. During a review of Resident 52's medical record and written note to Medical doctor (MD 1), dated 8/21/24, the record and note written by facility's Consultant Pharmacist (CP) indicated Resident has order for Ativan half a milligram every 4 hour as needed. CMS guidelines recommend 14-day duration for PRN psychotropic unless 14-day duration is contraindicated for patient. Please assess continued need for current order . The note further indicated the MD 1 signed the continuation of the lorazepam without a clinical justification for continued use and no specific duration was provided for re-assessment. Phone call to CP during the Department visit was not answered. 2. A. During a concurrent interview with Licensed Vocational Nurse (LN) 3, and record review of Resident 52's medical record, on 3/20/25, at 9:18 AM, LN3 confirmed Resident 52's care plan (a plan of care and guidance to nursing staff on how to safely handle medical and behavioral needs of the residents) and MAR did not have patient specific guidelines on use of non-pharmacological interventions 055662 Page 3 of 7 055662 03/21/2025 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0758 or alternatives for helping resident for use of lorazepam to manage anxiety. Level of Harm - Minimal harm or potential for actual harm B. During a concurrent interview with the Assistant Director of Nursing (ADON), and record review of Resident 44's medical record on 3/21/25, at 11 AM, the ADON confirmed Resident 44's care plan and the MAR for anxiety did not have patient specific guidelines on use of non-pharmacological interventions or alternatives for helping resident for use of Buspar (or buspirone, a drug used to treat anxiety) to manage anxiety. The ADON further stated, non-pharmacological interventions were important interventions and would have allowed Resident 44's management of anxiety without resorting to medication use. Residents Affected - Few During an interview with Assistant Director of Nursing (ADON), on 3/21/25, at 10:57 AM, in his office, the ADON stated the medical doctors review all medications on monthly basis and use of as needed (PRN) psychotropic medications and its duration of the use was up to the doctor to decide, and facility followed what the doctors wanted. The ADON stated the pharmacy's recommendation were shared with the doctor. During a telephone interview with MD 1, on 3/21/25, at 12:47 PM, MD 1 stated he was not clear on the use and duration of as needed of psychotropic medications in addition to routine use. MD 1 stated the nursing staff would assess the need for the continuation, and he would follow their recommendation. Review of the facility's policy titled, Freedom from abuse, neglect and Exploitation- Chemical Restraints, dated 3/14/25, the policy under Purpose indicated, .The resident has a right to be free from abuse, including any chemical restraint not required to treat the residents' medical symptoms. Chemical restraints imposed for purposes of discipline or convenience are prohibited . The policy further indicated, .The nature, degree, duration, and probability of side effects and significant risk and or drug interaction with other drugs the resident is receiving .All exhibited behavior will be documented monthly on the physician orders and will be reviewed by physician. The use of psychotherapeutic medication will be reviewed quarterly at the Health Team Conference .Recommendations for increased, decreased, same dosage, continued or revocation of psychotropic medication will be provided. If a decision is made to discontinue drug the prescriber is responsible for planning any necessary gradual dose reduction as well as possible . The policy did not address use of PRN (or as needed) medication use and durations. The policy did not address use of non-pharmacological interventions during nursing care. Review of the facility's policy titled, Psychotropic Drug Use, dated 11/2012, the policy indicated, .To monitor for adverse or side effects of psychotropic medications, all residents who receive psychotropic medications will be monitored for the side effects. Residents receiving psychotropic medications will be reviewed by the pharmacist and the doctor for possible dose reduction or discontinuation. The physician will document the risks versus the benefits statements in the progress notes every 6 months . The policy did not address use of PRN (or as needed) medication use and durations. The policy did not address use of non-pharmacological interventions during nursing care. 055662 Page 4 of 7 055662 03/21/2025 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure documentation and monitoring of temperature range in one out of one medication refrigerator for a period of 6 months with resident census of 63. This failed practice may have contributed to unsafe storage of refrigerated medication resulting in altered potency and unusable medications based on manufacturer specification. Findings: During a concurrent observation and interview on 3/18/25, at 9:20 AM, with Licensed Vocational Nurse (LN) 4, the refrigerator at North hall station stored multiple containers of flu vaccine (flu same as influenza, an infection affecting the breathing system), resident's insulin (medication used to treat blood sugar disease), other refrigerated prescription medications, and Emergency Kit (or Ekit, a sealed container containing insulin and other refrigerated products for urgent use). The thermometer inside the refrigerator was within the approved and safe temperature range (36-to-46-degree Fahrenheit [a measure of temperature]). LN 4 was unable to provide North hall station refrigerator temperature log documentation. During a concurrent interview with LN 3 and record review of facility's temperature log document (for North Hall), titled NOC log (NOC is night shift documentation), on 3/19/25, at 9:45 AM, the temperature log for March 2025 was only documented once on 3/18/25 at 11:30 PM. LN 3 stated the refrigerator temperatures were not logged since October of 2024 and prior to that the temperature was logged once a day that went as far as January of 2024. LN 3 further stated, if vaccines were stored in the refrigerator, the temperatures should have been monitored twice a day for safe vaccines storage. LN 3 stated the vaccine would not have been safe to administer if the temperature were not within the range as it was not monitored. During an interview with the Director of Nursing (DON), on 3/19/25, at 2:30 PM, the DON stated there was a misunderstanding with staff who were filling out only partial portions of the refrigerator temperature log. The DON stated refrigerator temperature should have been monitored twice a day for consistency for proper medication and vaccine storage. A review of the facility policy and procedure (P&P) titled, Storage of Medications, last revision date of April 2019, indicated, .drugs and biologicals used in the facility are stored in locked compartments under proper temperature . A review of the facility P&P titled, Pharmacy Services, last revised 2/19/20, indicated, .Medications are stored at appropriate temperatures .Medications requiring refrigeration are stored in a refrigerator at a temperature between 36 degrees Fahrenheit and 46 degrees Fahrenheit . Review of Center for Disease Control (CDC, a federal public health protection agency) guidelines on safe storage of vaccine, [last accessed on 3/24/25, via https://www.cdc.gov/vaccines/hcp/storage-handling/resources.html#cdc_listing_res6-vaccine-temperature-monitoring, and https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf ], indicated, .Failure to store and handle vaccines 055662 Page 5 of 7 055662 03/21/2025 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease .Proper vaccine storage and handling play critical roles in efforts to prevent vaccine-preventable diseases. Vaccines exposed to storage temperatures outside the recommended ranges may have reduced potency, creating limited protection and resulting in the revaccination of patients and thousands of dollars in wasted vaccine . The CDC document further indicated, .Keep your storage units and vaccines within the appropriate temperature ranges. Check and record storage unit min/max temperatures at the start of each workday. If your device does not display min/max temperatures, then check and record current temperature a minimum of 2 times (at start and end of workday) . 055662 Page 6 of 7 055662 03/21/2025 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to ensure residents receiving regular chicken pot pie received the appropriate nutritive content as prescribed by a physician when serving sizes were smaller than ordered for 19 residents with a census of 63. This failure had the potential of leading to malnutrition and weight loss for the 19 residents receiving a regular diet. Findings: During an observation of the lunch meal on 3/19/25, at 11:15 a.m., the service utensils were noted for the various foods. The steamed regular broccoli was noted to have a gray handled spoodle (unique cross between a serving spoon and a ladle which allows to efficiently scoop and serve just the right amount of food). The mashed potatoes was noted to have a blue handled spoodle. The chicken pot pie was noted to have a black handled spoodle placed in the pan and was used to scoop the chicken pot pie during the meal plating for the residents on the first food cart. During a review of the undated facility provided cook's spread sheet indicated the serving amounts for the regular chicken pot pie was 8 ounces spoodle (oz, a unit of measurement equivalent to 1 cup). The spread sheet also indicated the different spoodle measurements as follows: 2 oz was equivalent to 1/4 cup, 3 oz was equivalent to 1/3 cup, 4 oz was equivalent to 1/2 cup, and 6 oz was equivalent to 3/4 cup. Since 4 oz was equivalent to 1/2 cup then 8 oz was equivalent to 1 cup. During a concurrent observation and interview on 3/19/25, at 12:10 p.m., with facility cook (C) and the Certified Dietary Manager (CDM), when asked to verify the measurement of the black handled spoodle used to scoop the chicken pot pie during meal plating, the C checked the label of the spoodle and stated the measurement written on the black spoodle was 6 oz. The CDM also checked and confirmed the black spoodle used was 6 oz. Both the C and the CDM stated the 8 oz spoodle should have been used to scoop the chicken pot pie as the spread sheet had indicated. Both the C and the CDM stated the 6 oz and the 8 oz spoodle had the same color. The C stated she should have checked the label to be sure she had the correct measurement of the spoodle. During an interview on 3/19/25, at 3:20 p.m., with the C and the CDM, the CDM concurred that the spoodle used for the chicken pot pie was incorrect to meet the portions for the residents on regular diet in the first cart. The C stated she should have checked to make sure she had the correct portion size. The CDM stated the 6 oz spoodle was not large enough and would lead to a decrease in amount of nutrients provided and would have an effect on residents who were on a weight loss program. During a review of the facility's policy and procedure titled, Portion Control, dated 3/2010, indicated, .All foods served conform to portion control specifications .To standardize portions for nutritional balance of diet .Standard portion sizes are determined for all food items, served in .traylines .The proper type and size serving utensils are used as per production chart . 055662 Page 7 of 7