Other·June 3, 2019

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 Health during a Federal Recertification survey. Representing the Department of Public Health: HFEN, 40583 HFEN, 34271 HFEN, 40327 HFEN, 34273 HFEN, 40623 The facility census was 79. The sample size was 41.

F582 SS=D Medicaid/Medicare Coverage/Liability Notice CFR(s): 483.10(g)(17)(18)(i)-(v)

F582 06/07/2019 §483.10(g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, 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: JI0F11 Facility ID: CA030000017 If continuation sheet 1 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, the facility did not provide 1 of 3 sampled residents (Resident 75) a "Skilled Nursing Facility Advance Beneficiary Notice of NonCoverage" (SNF ABN). This failure placed Resident 75 at risk of not being informed of their responsibility to pay for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 2 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 any services received after their Medicare coverage ended. Findings: During a concurrent interview and record review with the executive director (ED) on 5/9/19 at 11:07 a.m., she verified Resident 75 was not provided a SNF ABN after her Medicare coverage ended. The ED acknowledged she was unaware that Resident 75 should have received a SNF ABN and stated it will be corrected.

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

F623 06/07/2019 §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 whenFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 3 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 (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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 4 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 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. §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 staff interviews and clinical record review, the facility failed to notify the local Long-Term Care (LTC) Ombudsman (advocate) of the residents' transfer to the local emergency room (ER) for 4 of 41 sampled residents, (Resident 51, Resident 5, Resident 73, and Resident 17). This failure denied Resident 51, Resident 5, Resident 73, and Resident 17 of the added protection of having the LTC Ombudsman being made aware of their transfer from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 5 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 Findings: Clinical record reviews revealed the following residents were transferred from the facility to the local ER: a. Resident 51 was transferred from the facility to the local ER on 3/27/19 and 4/12/19; b. Resident 5 was transferred from the facility to the local ER on 3/19/19 and 4/8/19; c. Resident 73 was transferred from the facility to the local ER on 3/15/19 and 4/5/19; and d. Resident 17 was transferred from the facility to the local ER on 1/15/19. Further clinical record review revealed there was no documented evidence that a notice of transfer/discharge was sent to the LTC Ombudsman for any of the ER transfers regarding Resident 51, Resident 5, Resident 73, and Resident 17. In a concurrent interview and record review on 5/7/19, at 4:43 p.m., licensed nurse (LN) 4 stated the facility had not been notifying the LTC Ombudsman when residents transferred to the ER. LN 4 stated there were no written notification sent to LTC Ombudsman. In a concurrent interview and record review on 5/8/19, at 11:42 a.m., the executive director (ED) confirmed transfer/discharge notices were not being sent to the LTC Ombudsman. The ED explained the LTC Ombudsman "Should have been notified [regarding residents transfer/discharge to ER]." A facility policy titled, "Transfer to Acute Hospital," revised 3/2/18, indicated "...To assure that the transfer of a resident for hospital admission or emergency room evaluation is carried out effectively by order of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 6 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 physician and with knowledge of the resident, the resident representative and nursing supervisor... Procedure...5. Retain documents...b. Transfer/Discharge Notification: original to resident/resident representative, copy to admission, FAX copy to LTC Ombudsman office..."

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 06/07/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, staff interviews, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) for 1 of 41 sampled residents (Resident 68) accurately reflected the resident's functional status (individual's ability to perform activities of daily living [ADLs]). This failure had the potential for Resident 68 to receive inaccurate care. Findings: Resident 68 was admitted to the facility with diagnoses which included dementia (a decline in mental ability) and abnormalities of gait and mobility. Resident 68 was observed sitting in a geri chair (recliner chair with wheels) while in the dining room on 5/6/19, at 11:30 a.m. Resident 68 did not move their geri chair on their own; staff moved the geri chair for Resident 68. A review of Resident 68's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 7 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 revealed the following: 1) A licensed nurse weekly summary dated 11/12/18, indicated, "...Transfers with a total lift and assist of one. Uses a wheelchair for mobility. Pushed by staff..." 2) Section G of the 11/13/18 MDS (used to assess functional status of the resident) showed Section G0110B1 was coded as "3" and Section G0110B2 was coded as "2" which indicated Resident 68 required extensive assistance of one person to transfer to or from the bed and wheelchair; Section G0110E1 was coded as "3" and Section G0110E2 was coded as "2" which indicated Resident 68 required extensive assistance of one person to move their wheelchair around the unit. 3) A licensed nurse weekly summary dated 2/4/19, indicated, "...Transfer with total lift assist of one. Use wheelchair for mobility, staff push..." 4) The 2/6/19 MDS showed Section G0110B1 was coded as "3" and Section G0110B2 was coded as "2" which indicated Resident 68 required extensive assistance of one person to transfer to or from the bed and wheelchair; Section G0110E1 was coded as "3" and Section G0110E2 was coded as "2" which indicated Resident 68 required extensive assistance of one person to move their wheelchair around the unit. 5) A licensed nurse weekly summary dated 4/25/19, indicated, "...Transfers with total lift and assist of one. Geri chair used for mobility, staff pushes..." 6) The 4/25/19 MDS showed Section G0110B1 was coded as "4" and Section G0110B2 was coded as "2" which indicated Resident 68 was totally dependent on one person to transfer to or from the bed and wheelchair; Section G0110E1 was coded as "4" and Section G0110E2 was coded as "2" which indicated Resident 68 was totally dependent on one person to move their wheelchair around the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 8 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 unit. In an interview with the MDS coordinator (MDSC) on 5/8/19, at 2:58 p.m., the MDSC verified the information on Resident 68's 11/13/18, 2/6/19, and 4/25/19 MDS. She acknowledged Section G0110B1 and Section G0110E1 was coded as "4" on the 4/25/19 MDS and this MDS was different from the 11/13/18 and the 2/6/19 MDS. The code of "4" indicated Resident 68 was totally dependent on staff for transfers and mobility. The MDSC stated Resident 68 was able to bear weight for transfer but needed staff assistance for support. In an interview with the assistant director of nurses (ADON) on 5/9/19, at 2:46 p.m., she stated Resident 68 did not self propel their wheelchair or geri chair. In a subsequent interview with the MDSC on 5/9/19, at 2:51 p.m., she explained, "There was no actual decline in Resident 68's functional status. The discrepancy [or change of code from "3" to "4"] was because staff started to use the stand lift (a mechanical device used to assist a resident who can bear weight from sitting to standing position) for Resident 68 so the nurse who filled out the most current MDS coded it as a "4". The MDSC verbalized the MDS assessment was "supposed to be based on the resident's ability and not what staff is doing for the resident."

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/07/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 9 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 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 observations and interviews, the facility failed to ensure proper storage of and allowed access to chemicals when a liquid drug deactivation container (Brand Name product that uses activated charcoal to neutralize the chemicals in pills, liquids, controlled substances and transdermal patches) was stored on the outside of three medication carts for a census of 79. This failure had the potential for staff, visitors, and residents to ingest the liquid charcoal, resulting in vomiting, and skin or eye irritation. Findings: During a concurrent medication pass observation and interview on 5/8/19 at 8:25 a.m., licensed nurse (LN) 2 was administering medications to Resident 18. LN 2 was reviewing the medications with Resident 18. Resident 18 had a calcium with vitamin D tablet in her hand and stated to LN 2 that she did not want to take it; the tablet then fell on the floor. LN 2 picked up the medication and stated she would place it in the container with the [Brand Name] drug deactivation liquid. The container was located on the left side of the medication cart approximately 10 inches off the floor. LN 2 was observed placing the tablet into the container. In an observation on 5/8/19, at 2:40 p.m., there were three medication carts in the facility. Each of these carts had a container with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 10 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 [Brand Name] liquid deactivation liquid stored on the left lower side of the cart. In a concurrent interview and observation on 5/8/19, at 2:55 p.m., with LN 1, LN 1 verified that the liquid drug deactivation containers were stored on the outside of the medication carts, were used to dispose of medication, and were accessible to anyone. In a concurrent interview and observation on 5/8/19, at 3:04 p.m., with the assistant director of nurses (ADON), the ADON stated the liquid drug deactivation container should be inside the medication cart as staff will not be able to monitor it at all times. An observation of the liquid drug deactivation container revealed it contained 16 ounces (a unit of measure) of activated carbon (charcoal), surfactants (substances that reduce surface tension), and neutralizing agents. The container indicated, "Warnings Ingestion of this products will induce vomiting. Keep out of reach of children May be harmful if swallowed. ...First aide eyes: If contact with eyes occur, flush with plenty of cool water for 15 minutes. Consult a physician."

F755 SS=F Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 06/07/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 11 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observations, staff interviews, and record review, the facility failed to: 1. Ensure proper disposition of medication when a container with medications, under a sink, in an unlocked storage room was accessible to anyone for a census of 79. This failure had the potential for staff, visitors, and residents to ingest the medication resulting in an overdose or death. 2. Ensure the medication administration route for bisacodyl suppository (a laxative administered rectally) was specified in the physician's order and medication administration record (MAR) for 17 of 25 sampled residents (Resident 5, Resident 9, Resident 10, Resident 17, Resident 18, Resident 22, Resident 28, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 12 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 31, Resident 34, Resident 35, Resident 50, Resident 54, Resident 55, Resident 57, Resident 59, Resident 68, and Resident 77). This failure placed Resident 5, Resident 9, Resident 10, Resident 17, Resident 18, Resident 22, Resident 28, Resident 31, Resident 34, Resident 35, Resident 50, Resident 54, Resident 55, Resident 57, Resident 59, Resident 68, and Resident 77 at potential risk for a medication administration error. Findings: 1. In a concurrent interview and observation on 5/8/19, at 2:30 p.m. with licensed nurse (LN) 2, LN 2 stated controlled medication patches are removed from the resident and documented by two nurses. When asked where were the patches disposed of, LN 2 asked a peer nurse, LN 1, who indicated the patches are placed in the Drug Buster container on the medication cart or in the storage room. LN 2 took the Department to an unlocked storage room where she obtained a key Velcroed to a paper towel dispenser next to the sink. LN 2 used the key labeled, "Under Sink Cabinet" to open a cabinet door under the sink. LN 2 pointed to a blue and white plastic container which did not have a locked top and was not secured. LN 2 opened the top of the plastic container and said, "See there's some fentanyl patches right there." The plastic container which was approximately 6 inches wide, 7 inches tall, and 8 inches deep was filled to within 2 inches from the top with discarded patches and multiple colored tablets/capsules. LN 2 stated anyone had access to this storage room. In a concurrent interview and observation on 5/8/19, at 3:04 p.m. with the assistant director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 13 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 of nurses (ADON), the ADON entered the unlocked storage room and confirmed there was a Velcroed key on the paper towel dispenser which opened the cabinet under the sink. The ADON confirmed there was a container, within this cabinet under the sink, that contained medication. The ADON stated this container of medication should have been picked up and incinerated a couple of months ago. The ADON verified the storage room was unlocked and anyone had access and the key was available to open the cabinet that stored the medication. Review of facility policy titled, Pharmacy Services Policy and Procedure updated 2/20/19 stipulated, "Purpose 1. To ensure that medications are handled in this facility in a manner that protects the safety and welfare of the resident. ...VIII. Storage of Medication ...C. Medications are made accessible only to licensed nursing, pharmacy and medical personnel at [facility name]. ...G. Discontinued Controlled Drugs or Refused Controlled Drugs 1. Controlled drugs refused by a resident: ...c. Refused medications are disposed of in a Drug Buster container ...XII. Disposal of Medication and Supplies ...D. CII discontinued medications will be disposed of in a Drug Buster container ...E. Pharmaceutical waste will be stored in a Drug Buster container ..."2. Resident 5, Resident 9, Resident 10, Resident 17, Resident 18, Resident 22, Resident 28, Resident 31, Resident 34, Resident 35, Resident 50, Resident 54, Resident 55, Resident 57, Resident 59, Resident 68, and Resident 77 were admitted to the facility with different diagnoses and on different dates. During a review of the clinical record for the aforementioned residents, the most current physician's orders and MARs included an order for, "Bisacodyl suppository daily as needed for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 14 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 constipation" or "Bisacodyl suppository daily as needed for bowel care." The administration route for the Bisacodyl order was not specified on the physician's orders or the MARs. In an interview with the Assistant Director of Nurses (ADON) and with the Staff Developer (SD) on 5/9/19, at 2:25 p.m., they reviewed the clinical record for the aforementioned residents and were unable to find the administration route for bisacodyl suppository on the physician's orders and on the MARs. The ADON verified the administration route for medications must be specified in the physician's order. The facility policy and procedure titled "Pharmacy Services Policy and Procedure" dated 2/20/19, indicated, "...No medications are administered to residents at [facility name] except upon the order of a person lawfully authorized to prescribe for and treat human illness. All such orders are given in writing, dated and signed by the person making the order. The name, quantity or duration of therapy, dosage, and time or frequency of administration, the route of administration, if other than oral, are all specified on the order..."

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 06/07/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 15 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and facility document review, the facility failed to maintain sanitary conditions during a meal preparation when a kitchen aide entered and walked around the kitchen without her hair being covered for a census of 79. This failure had the potential for food to be contaminated, placing the residents at risk of getting a food borne illness. Findings: During the Initial Tour of the kitchen on 5/6/19, at 7:45 a.m., the dietary supervisor (DS) stated when anyone enters the kitchen they are to put on a hair net. During an observation on 5/8/19, at 11:37 a.m., a female entered the kitchen through a door connected to a facility hallway. She walked from the door, the full length of the kitchen to the DS's office, passing the food holding area where lunch was being prepped, exited the office and then walked back the full length of the kitchen to a hallway next to the door she entered. She was not wearing any form of head covering to contain her hair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 16 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 In an interview on 5/8/19, at 11:43 a.m. with the female (kitchen aide), who entered the kitchen with no head covering, she stated she worked in the kitchen for little over a month, three days a week. When she was asked about the facility policy on wearing hair nets, she stated one is to be worn while in the kitchen. She confirmed she walked into the kitchen, to the DS's office, and walked back through the kitchen without a hair net. A review of a facility document titled, Dress Code for Women and Men, dated 2018 stipulated, "PROPER DRESS: Women: ...6. Hair net or hat which completely covers the hair ...Men: ... 6. Hat for hair, if hair is short 7. Hair net for hair, if hair is long (over the ears or longer)."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 06/07/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §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)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 17 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 18 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, staff interviews, and record review, the facility failed to implement its infection control program for 6 residents (Resident 12, Resident 34, Resident 36, Resident 40, Resident 41, and Resident 49) out of a census of 79 when staff did not perform proper hand hygiene while assisting residents with meals. This failure had the potential to spread infection to Resident 12, Resident 34, Resident 36, Resident 40, Resident 41, and Resident 49. Findings: 1. During dining observation on 5/6/19, at 12:22 p.m., certified nurse assistant (CNA) 1 touched Resident 68's pillow and geri chair (recliner chair with wheels) to assist another CNA to properly position Resident 68 for lunch. After touching Resident 68's pillow and geri chair, CNA 1 assisted Resident 34 to eat without performing hand hygiene first. In an interview with CNA 1 on 5/6/19, at 12:56 p.m., she stated she should have washed her hands after touching Resident 68's pillow and geri chair. 2. In a dining observation on 5/6/19, at 12:26 p.m., licensed nurse (LN) 3 touched a female resident's wheelchair to move the resident away from the exit door. LN 3 then went to Resident 12, lightly rubbed her on her chest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 19 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 and assisted Resident 12 to drink milk out of a glass without performing hand hygiene. LN 3 then sat down with Resident 41, touched Resident 41's spoon and glass of milk, and encouraged Resident 41 to eat and drink more. LN 3 then got up and pushed Resident 49's wheelchair as he headed out of the dining room. LN 3 then went over to Resident 40 and touched her glass and spoon, and encouraged her to eat more. LN 3 did not perform hand hygiene in between residents. In an interview with LN 3 on 5/6/19, at 12:54 p.m., she stated she was supposed to sanitize her hands after touching a resident's wheelchair. 3. In a dining observation on 5/6/19, at 12:34 p.m., CNA 2 moved a female resident's wheelchair away from the exit door and lightly rubbed the female resident's back. CNA 2 then sat down next to Resident 36, rubbed Resident 36's back, then touched Resident 36's glass of water to encourage Resident 36 to drink. CNA 2 did not perform hand hygiene in between residents. In an interview with CNA 2 on 5/6/19, at 12:50 p.m., she said she was supposed to wash hands or use hand sanitizer after touching a resident's wheelchair. In an interview with the infection control nurse (ICN) on 5/9/19, at 2:25 p.m., she said staff must wash hands before assisting a resident to eat. The ICN added staff must sanitize or wash their hands after touching a dirty surface. The ICN clarified, another resident's wheelchair or another resident was considered a dirty surface. The facility policy and procedure titled, "Hand Washing" dated 11/2015, indicated, "...Hands FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 20 of 21 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: _______________ 055662 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BETHANY HOME SOCIETY SAN JOAQUIN COUNTY 930 W Main Street Ripon, CA 95366 (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 are to be cleansed: a. between residents...b. before passing out trays or handling food...c. following any contact with any soiled items/surface..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JI0F11 Facility ID: CA030000017 If continuation sheet 21 of 21