Health inspection·September 23, 2022

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sitting in her w/c. CNA 3 stated Resident 20 had fallen many times. CNA 3 stated the self-releasing belt was ordered to be applied when Resident 20 was in her w/c due to Resident 20 being a high risk for falls. CNA 3 stated not all residents knew how to take the self-releasing belt off. CNA 3 stated the seatbelt was a form of physical restraint but was ordered by the physician. CNA 3 stated he checked the belts each shift to make sure they were working properly. CNA 3 stated Resident 20 was not able to release the belt. CNA 3 stated Resident 20 has removed the belt several times before and Resident 20 now has a self-releasing belt with an alarm that goes off when the belt was released. CNA 3 stated when the alarm was set off, the resident was already up and could potentially fall so once he heard an alarm going off, he would stop what he was doing and go to the resident as soon as possible to prevent the resident from falling. CNA 3 stated the alarms could not prevent falls, but it could alert the staff that a resident was attempting to or had already gotten out of their w/c. CNA 3 stated the risks of using seatbelts with residents in a w/c was if the resident leaned forward, the w/c could tip forward. CNA stated he had seen this happen two times before in the past. During a concurrent interview and record review on 9/23/22, at 4:04 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 20's Order Summary Report (Orders), dated 9/23/22, Resident 20's Care Plan (CP), dated 9/23/22, and MDS (Minimum Data Set), dated 8/19/22 was reviewed. The MDSC stated the Orders indicated, Resident 20 had new orders for self-releasing belt with sensor alarm on 8/4/22. The MDSC stated the CP indicated Resident 20 had a fall on 8/5/22. The MDSC stated Resident 20 was able to release the belt herself and there were no risks of using the self-releasing belt. The MDSC stated she was not sure if a risk assessment was completed prior to applying the self-releasing belt. The MDSC stated the purpose of the restraint was to prevent falls for Resident 20. The MDSC stated the MDS indicated Resident 20 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 4 and a score of 0-7 indicated a severe impairment in cognition. The MDSC stated, based on Resident 20's BIMS, she was not able to release the seat belt on her own and the seat belt was considered a restraint. During a review of Resident 20's Restraint-Physical (Initial Evaluation), dated 9/23/22, the Initial Evaluation indicated, Resident 20 had not been assessed for physical restraint use prior to the self-releasing seat belt being applied to Resident 20 which was ordered on 8/4/22. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, dated 4/2017, the P&P 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 that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . if the resident cannot remove a device in the manner in which the staff applied it given that resident's physical condition . and this restricts his/her typical ability to change position or place, that device is considered a restraint . prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 2 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan for ten of ten sampled residents (1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from the surveyor, the consent, physician order and care plan were implemented on 9/22/22. 4. Resident 13 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 5. Resident 10 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 6. Resident 4 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 7. Resident 222 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 8. Resident 5 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 9. Resident 14 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 10. Resident 1 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. These failures had the potential to place Resident 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222 at risk for decreased freedom of movement, entrapment and/or injury. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 3 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm 1. During an observation on 9/20/22, at 9:06 a.m., in Resident 7's room, Resident 7 was lying in bed with two bed rails up. During an observation on 9/21/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. Residents Affected - Many During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/15/22, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 indicating severe cognitive impairment (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills] ,8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a concurrent observation and interview on 9/21/22, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. CNA 1 stated Resident 7 had four bed rails up to keep pillows in place. CNA 1 stated she placed pillows between Resident 7 and the bed rail. CNA 1 stated Resident 7 constantly moved in bed causing her leg to go through the side rail. CNA 1 stated Resident 7 would not be able to lower the side rail due to requiring extensive assistance and cognitive status. CNA 1 stated she had witnessed Resident 7's foot through the bed rail in the past. During a concurrent interview and record review on 9/21/22, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 7 did not have a consent or entrapment risk assessment in place for bed rails. LVN 1 stated pillows were implemented in between the bed rail because Resident 7 constantly moved in bed causing her arm or leg to go through the bed rail. LVN 1 stated the pillows were placed to prevent injury from the bed rail. LVN 1 stated it was the licensed nurses responsibility to develop a care plan once an intervention was started such as the bed rail. During a review of Resident 7's care plan dated 7/14/22 was reviewed. The care plan indicated, . High risk for falls . History of falls . Unaware of safety needs . large pillows to be used while resident is in bed to prevent resident from injuring self . During an interview on 9/22/22, at 9:39 a.m., with LVN 1, LVN 1 stated bed rails can cause strangulation and injury. 2. During an observation on 9/20/22, at 2:02 p.m., in Resident 16's room, Resident 16 was lying in bed with two bed rails up. During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 1:57 p.m., with CNA 1, in Resident 16's room, Resident 16 was lying in bed with two bed rails up. CNA 1 stated Resident 16 had two side rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:47 p.m., with LVN 1, Resident 16's clinical record was reviewed. LVN 1 reviewed the care plans. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 16 did not have a consent or entrapment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 4 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 risk assessment in place for bed rails. Level of Harm - Minimal harm or potential for actual harm 3. During an observation on 9/20/22, at 10:54 a.m., in Resident 15's room, Resident 15 was lying in bed with two bed rails up. Residents Affected - Many During a review of Resident 15's MDS, dated 7/29/22, the MDS indicated, Resident 15's BIMS score was 7 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/22/22, at 11:35 a.m., with CNA 3, in Resident 15's room, Resident 15 was lying in bed with two bed rails up. CNA 3 stated Resident 15 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/23/22, at 10:31 a.m., with LVN 1, Resident 15's clinical record was reviewed. LVN 1 stated, Resident 15 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 15 had bed rail use prior to 9/22/22. 4. During an observation on 9/21/22, at 9:13 a.m., in Resident 13's room, Resident 13 was lying in bed with two bed rails up. During a review of Resident 13's MDS, dated 7/22/22, the MDS indicated, Resident 13's BIMS score was 4 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 9:34 a.m., with CNA 2, in Resident 13's room, Resident 13 was lying in bed with two bed rails up. CNA 2 stated Resident 13 had two bed rails up which were used for protection to prevent fall. During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with LVN 1, Resident 13's clinical record was reviewed. LVN 1 stated, Resident 13 did not have a consent, physician order or entrapment risk assessment in place for bed rails. 5. During an observation on 9/21/22, at 9:39 a.m., in Resident 10's room, Resident 10 was lying in bed with two bed rails up. During a review of Resident 10's MDS, dated 7/27/22, the MDS indicated, Resident 10's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 10:13 a.m., with CNA 1, in Resident 10's room, Resident 10 was lying in bed with two bed rails up. CNA 1 stated Resident 10 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:27 p.m., with LVN 1, Resident 10's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 10 did not have a consent or entrapment risk assessment in place for bed rails. 6. During a concurrent observation and interview on 9/21/22, at 1:50 p.m., with CNA 1, in Resident 4's room, Resident 4 was lying in bed with two bed rails up. CNA 1 stated Resident 4 had two bed rails up which were used to prevent falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 5 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/21/22, at 2:44 p.m., with LVN 1, Resident 4's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 4 did not have a consent or entrapment risk assessment in place for bed rails. 7. During a concurrent observation and interview on 9/21/22, at 1:54 p.m., with CNA 1, in Resident 222's room, Resident 222 was lying in bed with two bed rails up, CNA 1 stated Resident 222 had two bed rails up. During a concurrent interview and record review on 9/21/22, at 3:21 p.m., with LVN 2, Resident 222's clinical record was reviewed. LVN 2 stated there was no care plan for bed rail use and no physician order. LVN 2 stated Resident 222 did not have a consent or entrapment risk assessment in place for side rails. LVN 2 stated she did not get an in-service training for bed rails. LVN 2 stated, it was a nursing measure to have two bed rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. 8. During a concurrent observation and interview on 9/22/22, at 11:40 a.m., with CNA 3, in Resident 5's room, Resident 5 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/8/22, the MDS indicated, Resident 5's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:33 a.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated, Resident 5 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 5 had bed rail use prior to 9/22/22. 9. During a concurrent observation and interview on 9/22/22, at 11:50 a.m., with CNA 3, in Resident 14's room, Resident 14 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/28/22, the MDS indicated, Resident 14's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:34 a.m., with LVN 1, Resident 14's clinical record was reviewed. LVN 1 stated, Resident 14 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 14 had bed rail use prior to 9/22/22. 10. During an interview on 9/21/22, at 3:21 p.m., with LVN 2, LVN 2 stated she had not had an in-service training for side rails. LVN 2 stated, it was a nursing measure to have two side rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 6 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 recall the last time she had seen the facility policy regarding side rail use. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 9/22/22, at 11:52 a.m., with CNA 3, in Resident 1's room, Resident 1 was lying in bed with two bed rails up. CNA 3 stated Resident 1 had two bed rails up which were used for safety to prevent fall. Residents Affected - Many During a review of Resident 15's MDS, dated 8/11/22, the MDS indicated, Resident 1's BIMS score was 0 out of 15 indicating severe cognitive impairment. During an interview on 9/22/22, at 3:18 p.m., with Maintenance (MN), MN stated he did not conduct routine preventative maintenance for bed rails. MN stated he addressed bed rails as needed when facility staff would report an issue. During a concurrent interview and record review on 9/22/22, at 9:43 a.m., with Director of Staff Development/Infection Preventionist (DSD/IP), the facility policy titled, Proper Use of Side Rails, dated 12/2016 was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DSD/IP stated the policy only applied when the bed rails were considered a restraint. DSD/IP reviewed her in-service binders and stated there were no in service training for bed rails. DSD/IP stated the bed rails were used as mobility devices therefore the policy did not pertain when only two bed rails were used. DSD/IP stated there was a risk for entrapment when bed rails were in use. During a concurrent interview and record review on 9/22/22, at 10:01 a.m., with Director of Nursing (DON), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DON stated it was the facility policy to include all the components as outlined in the policy prior to bed rail use. DON stated the bed rails were in use for safety but can be a risk for entrapment. DON stated it was the responsibility of Licensed Nurses to develop a care plan for bed rail use to maintain continuity of care. During an interview on 9/22/22, at 11:56 a.m., with DON, the DON stated the Interdisciplinary Team (IDT) consisted of multidisciplinary staff. The DON stated the IDT meetings were held daily except for weekends. DON stated she did not recall when or if bed rails were discussed in the IDT meetings. During a concurrent interview and record review on 9/23/22, at 10:29 a.m., with LVN 1, Resident 1's clinical record was reviewed. LVN 1 stated, Resident 1 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 1 had bed rails use prior to 9/22/22. During a review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the policy indicated, . A comprehensive, person-centered care plan that includes measurable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 7 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Residents Affected - Many During a review of the facility job description titled, Charge Nurse, undated was reviewed. The job description indicated, . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures . Assist in writing and updating Resident Assessment and Comprehensive Care Plans . During a review of the facility policy titled, Proper Use of Side Rails, dated 12/2016, the policy indicated, . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Documentation will indicate if less restrictive approaches are no successful, prior to considering the use of side rail . The risk and benefits of side rails will be considered for each resident . Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefit and risks . The resident will be checked periodically for safety relative to side rail use . When side rail usage Is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being use) . Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions . During a review of professional reference from the FDA- Food and Drug Administration, titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-c dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 8 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 9 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure ten of ten Residents (Residents 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered position) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from the surveyor , the consent, physician order and care plan were implemented on 9/22/22. 4. Resident 13 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 5. Resident 10 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 6. Resident 4 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 7. Resident 222 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 8. Resident 5 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. 9. Resident 14 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 10 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 10. Resident 1 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. These failures had the potential to place Resident 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222 at risk for decreased freedom of movement, entrapment and/or injury. Following the identification of the deficient practices related to bedrails, the facility developed and implemented care plans, assessed residents for risk of entrapment and obtained consents for all ten residents . Findings: 1. During an observation on 9/20/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During an observation on 9/21/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/15/22, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 indicating severe cognitive impairment (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a concurrent observation and interview on 9/21/22, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. CNA 1 stated Resident 7 had four bed rails up to keep pillows in place. CNA 1 stated she placed pillows between Resident 7 and the bed rail. CNA 1 stated Resident 7 constantly moved in bed causing her leg to go through the side rail. CNA 1 stated Resident 7 would not be able to lower the side rail due to requiring extensive assistance and cognitive status. CNA 1 stated she had witnessed Resident 7's foot through the bed rail in the past. During a concurrent interview and record review on 9/21/22, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 7 did not have a consent or entrapment risk assessment in place for bed rails. LVN 1 stated pillows were implemented in between the bed rail because Resident 7 constantly moved in bed causing her arm or leg to go through the bed rail. LVN 1 stated the pillows were placed to prevent injury from the bed rail. LVN 1 stated it was the licensed nurses' responsibility to develop a care plan once an intervention was started such as the bed rail. During a review of Resident 7's care plan dated 7/14/22 was reviewed. The care plan indicated, . High risk for falls . History of falls . Unaware of safety needs . large pillows to be used while resident is in bed to prevent resident from injuring self . During an interview on 9/22/22, at 9:39 a.m., with LVN 1, LVN 1 stated bed rails can cause strangulation and injury. 2. During an observation on 9/20/22, at 2:02 p.m., in Resident 16's room, Resident 16 was lying in bed with two bed rails up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 11 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 1:57 p.m., with CNA 1, in Resident 16's room, Resident 16 was lying in bed with two bed rails up. CNA 1 stated Resident 16 had two side rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:47 p.m., with LVN 1, Resident 16's clinical record was reviewed. LVN 1 reviewed the care plans. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 16 did not have a consent or entrapment risk assessment in place for bed rails. 3. During an observation on 9/20/22, at 10:54 a.m., with Resident 15, in Resident 15's room, Resident 15 was lying in bed with two upper bed rails raised up. During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15's BIMS score was 7 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/22/22, at 11:35 a.m., with CNA 3, in Resident 15's room, Resident 15 was lying in bed with two bed rails up. CNA 3 stated Resident 15 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/23/22, at 10:31 a.m., with LVN 1, Resident 15's clinical record was reviewed. LVN 1 stated, Resident 15 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 15 had bed rail use prior to 9/22/22. 4. During an observation on 9/21/22, at 9:13 a.m., in Resident 13's room, Resident 13 was lying in bed with two bed rails up. During a review of Resident 13's MDS, dated 7/22/22, the MDS indicated, Resident 13's BIMS score was 4 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 9:34 a.m., with CNA 2, in Resident 13's room, Resident 13 was lying in bed with two bed rails up. CNA 2 stated Resident 13 had two bed rails up which were used for protection to prevent fall. During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with LVN 1, Resident 13's clinical record was reviewed. LVN 1 stated, Resident 13 did not have a consent, physician order or entrapment risk assessment in place for bed rails. 5. During an observation on 9/21/22, at 9:39 a.m., in Resident 10's room, Resident 10 was lying in bed with two upper bed rails raised up. During a review of Resident 10's MDS, dated 7/27/22, the MDS indicated, Resident 10's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 10:13 a.m., with CNA 1, in Resident 10's room, Resident 10 was lying in bed with two upper bed rails raised up. CNA 1 stated Resident 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 12 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 had two bed rails up which were used for mobility to turn and reposition in bed. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 9/21/22, at 2:27 p.m., with LVN 1, Resident 10's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 10 did not have a consent or entrapment risk assessment in place for bed rails. Residents Affected - Many 6. During a concurrent observation and interview on 9/21/22, at 1:50 p.m., with CNA 1, in Resident 4's room, Resident 4 was lying in bed with two upper bed rails raised up. CNA 1 stated Resident 4 had two bed rails up which were used to prevent falls. During a review of Resident 4's MDS, dated 7/4/22, the MDS indicated, Resident 4's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/21/22, at 2:44 p.m., with LVN 1, Resident 4's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order . LVN 1 stated Resident 4 did not have a consent or entrapment risk assessment in place for bed rails. 7. During a concurrent observation and interview on 9/21/22, at 1:54 p.m., with CNA 1, in Resident 222's room, Resident 222 was lying in bed with two upper bed rails raised up, CNA 1 stated Resident 222 had two upper bed rails raised. During a concurrent interview and record review on 9/21/22, at 3:21 p.m., with LVN 2, Resident 222's clinical record was reviewed. LVN 2 stated there was no care plan for bed rail use and no physician order. LVN 2 stated Resident 222 did not have a consent or entrapment risk assessment in place for side rails . LVN 2 stated she had not had an in service training for bed rails. LVN 2 stated, it was a nursing measure to have two bed rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. 8. During a concurrent observation and interview on 9/22/22, at 11:40 a.m., with CNA 3, in Resident 5's room, Resident 5 was lying in bed with two upper bed rails raised up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/8/22, the MDS indicated, Resident 5's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:33 a.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated Resident 5 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 5 had bed rail use prior to 9/22/22. 9. During a concurrent observation and interview on 9/22/22, at 11:50 a.m., with CNA 3, in Resident 14's room, Resident 14 was lying in bed with two upper bed rails raised up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/28/22, the MDS indicated, Resident 14's BIMS score (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 13 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 was 0 out of 15 indicating severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 9/23/22, at 10:34 a.m., with LVN 1, Resident 14's clinical record was reviewed. LVN 1 stated Resident 14 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 14 had bed rail use prior to 9/22/22. Residents Affected - Many 10. During a concurrent observation and interview on 9/22/22, at 11:52 a.m., with CNA 3, in Resident 1's room, Resident 1 was lying in bed with two upper bed rails raised up. CNA 3 stated Resident 1 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 8/11/22, the MDS indicated, Resident 1's BIMS score was 0 out of 15 indicating severe cognitive impairment. During an interview on 9/22/22, at 3:18 p.m., with Maintenance (MN), MN stated he did not conduct routine preventative maintenance for bed rails such as checking for loose side rails. MN stated he addresses bed rails as needed when facility staff would report an issue. During a concurrent interview and record review on 9/22/22, at 9:43 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . The DSD/IP stated the policy only applied when the bed rails were considered a restraint (limiting freedom of movement. The DSD/IP reviewed her in-service binders. The DSD/IP stated there were no in-service training for bed rails. The DSD/IP stated the bed rails were used as mobility devices therefore the policy did not pertain when only two bed rails were used. The DSD/IP stated there was a risk for entrapment when bed rails were in use. During a concurrent interview and record review on 9/22/22, at 10:01 a.m., with the Director of Nursing (DON), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . The DON stated it was the facility policy to include all the components as outlined in the policy prior to bed rail use. The DON stated the bed rails were in use for safety but can be a risk for entrapment. The DON stated it was the responsibility of Licensed Nurses to develop a care plan for bed rail use to maintain continuity of care. During an interview on 9/22/22, at 11:56 a.m., with the DON, the DON stated the Interdisciplinary Team (IDT) consisted of multidisciplinary staff. The DON stated the IDT meetings were held daily except for weekends. The DON stated she did not recall when or if bed rails were discussed in the IDT meetings . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 14 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent interview and record review on 9/23/22, at 10:29 a.m., with LVN 1, Resident 1's clinical record was reviewed. LVN 1 stated Resident 1 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 1 had bed rails use prior to 9/22/22. During a review of the facility policy titled, Proper Use of Side Rails, dated 12/2016 was reviewed. The policy indicated, . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Documentation will indicate if less restrictive approaches are no successful, prior to considering the use of side rail . The risk and benefits of side rails will be considered for each resident . Consent for side rail use will be obtained from the resident or legal representative,after presenting potential benefit and risks . The resident will be checked periodically for safety relative to side rail use . When side rail usage Is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being use) . Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological (disorders or other medical conditions . During a review of the facility job description titled, Charge Nurse, undated, was reviewed. The job description indicated, . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures . Assist in writing and updating Resident Assessment and Comprehensive Care Plans . During a review of professional reference from the FDA Food and Drug Administration, titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical devices/hospital beds/guide bed safety bed rails hospitals nursing homes and home health care facts dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm,such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed, from performing routine activities such as going to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 15 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 bathroom or retrieving something from a closet . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 16 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Licensed Nurses have the competencies necessary to meet the needs of the residents for ten of ten sampled residents (Residents 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) and Licensed Vocational Nurse (LVN) 2 and Director of Staff Development DSD/IP did not have training and competencies on the proper use of bed rails when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 4. Resident 13 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 5. Resident 10 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 6. Resident 4 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 7. Resident 222 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 8. Resident 5 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 9. Resident 14 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 10. Resident 1 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from surveyor, the consent, physician order and care plan were implemented on 9/22/22. These failures had the potential to place Resident 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222 at risk for decreased freedom of movement, entrapment and/or injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 17 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During an observation on 9/20/22, at 9:06 a.m., in Resident 7's room, Resident 7 was lying in bed with two bed rails up. Residents Affected - Few During an observation on 9/21/22, at 9:06 a.m., with Resident 7, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/15/22, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 0 out of 15 indicating severe cognitive impairment (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills] ,8-12 moderate cognitive impairment, and 13-15 cognitively intact). During a concurrent observation and interview on 9/21/22, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 7's room, Resident 7 was lying in bed with four bed rails up. CNA 1 stated Resident 7 had four bed rails up to keep pillows in place. CNA 1 stated she placed pillows between Resident 7 and the bed rail. CNA 1 stated Resident 7 constantly moved in bed causing her leg to go through the side rail. CNA 1 stated Resident 7 would not be able to lower the side rail due to requiring extensive assistance and cognitive status. CNA 1 stated she had witnessed Resident 7's foot through the bed rail in the past. During a concurrent interview and record review on 9/21/22, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 7's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 7 did not have a consent or entrapment risk assessment in place for bed rails. LVN 1 stated pillows were implemented in between the bed rail because Resident 7 constantly moved in bed causing her arm or leg to go through the bed rail. LVN 1 stated the pillows were placed to prevent injury from the bed rail. LVN 1 stated it was the licensed nurses responsibility to develop a care plan once an intervention was started such as the bed rail. During a review of Resident 7's care plan dated 7/14/22 was reviewed. The care plan indicated, . High risk for falls . History of falls . Unaware of safety needs . large pillows to be used while resident is in bed to prevent resident from injuring self . During an interview on 9/22/22, at 9:39 a.m., with LVN 1, LVN 1 stated bed rails can cause strangulation and injury. 2. During an observation on 9/20/22, at 2:02 p.m., in Resident 16's room, Resident 16 was lying in bed with two bed rails up. During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 1:57 p.m., with CNA 1, in Resident 16's room, Resident 16 was lying in bed with two bed rails up. CNA 1 stated Resident 16 had two side rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:47 p.m., with LVN 1, Resident 16's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 18 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical record was reviewed. LVN 1 reviewed the care plans. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 16 did not have a consent or entrapment risk assessment in place for bed rails. 3. During an observation on 9/20/22, at 10:54 a.m., in Resident 15's room, Resident 15 was lying in bed with two bed rails up. During a review of Resident 15's MDS, dated 7/29/22, the MDS indicated, Resident 15's BIMS score was 7 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/22/22, at 11:35 a.m., with CNA 3, in Resident 15's room, Resident 15 was lying in bed with two bed rails up. CNA 3 stated Resident 15 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/23/22, at 10:31 a.m., with LVN 1, Resident 15's clinical record was reviewed. LVN 1 stated, Resident 15 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 15 had bed rail use prior to 9/22/22. 4. During an observation on 9/21/22, at 9:13 a.m., in Resident 13's room, Resident 13 was lying in bed with two bed rails up. During a review of Resident 13's MDS, dated 7/22/22, the MDS indicated, Resident 13's BIMS score was 4 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 9:34 a.m., with CNA 2, in Resident 13's room, Resident 13 was lying in bed with two bed rails up. CNA 2 stated Resident 13 had two bed rails up which were used for protection to prevent fall. During a concurrent interview and record review on 9/21/22, at 2:42 p.m., with LVN 1, Resident 13's clinical record was reviewed. LVN 1 stated, Resident 13 did not have a consent, physician order or entrapment risk assessment in place for bed rails. 5. During an observation on 9/21/22, at 9:39 a.m., in Resident 10's room, Resident 10 was lying in bed with two bed rails up. During a review of Resident 10's MDS, dated 7/27/22, the MDS indicated, Resident 10's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent observation and interview on 9/21/22, at 10:13 a.m., with CNA 1, in Resident 10's room, Resident 10 was lying in bed with two bed rails up. CNA 1 stated Resident 10 had two bed rails up which were used for mobility to turn and reposition in bed. During a concurrent interview and record review on 9/21/22, at 2:27 p.m., with LVN 1, Resident 10's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 10 did not have a consent or entrapment risk assessment in place for bed rails. 6. During a concurrent observation and interview on 9/21/22, at 1:50 p.m., with CNA 1, in Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 19 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm 4's room, Resident 4 was lying in bed with two bed rails up. CNA 1 stated Resident 4 had two bed rails up which were used to prevent falls. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's BIMS score was 0 out of 15 indicating severe cognitive impairment. Residents Affected - Few During a concurrent interview and record review on 9/21/22, at 2:44 p.m., with LVN 1, Resident 4's clinical record was reviewed. LVN 1 stated there was no care plan for bed rail use and no physician order. LVN 1 stated Resident 4 did not have a consent or entrapment risk assessment in place for bed rails. 7. During a concurrent observation and interview on 9/21/22, at 1:54 p.m., with CNA 1, in Resident 222's room, Resident 222 was lying in bed with two bed rails up, CNA 1 stated Resident 222 had two bed rails up. During a concurrent interview and record review on 9/21/22, at 3:21 p.m., with LVN 2, Resident 222's clinical record was reviewed. LVN 2 stated there was no care plan for bed rail use and no physician order. LVN 2 stated Resident 222 did not have a consent or entrapment risk assessment in place for side rails. LVN 2 stated she did not get an in-service training for bed rails. LVN 2 stated, it was a nursing measure to have two bed rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. 8. During a concurrent observation and interview on 9/22/22, at 11:40 a.m., with CNA 3, in Resident 5's room, Resident 5 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/8/22, the MDS indicated, Resident 5's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:33 a.m., with LVN 1, Resident 5's clinical record was reviewed. LVN 1 stated, Resident 5 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 5 had bed rail use prior to 9/22/22. 9. During a concurrent observation and interview on 9/22/22, at 11:50 a.m., with CNA 3, in Resident 14's room, Resident 14 was lying in bed with two bed rails up. CNA 3 stated Resident 5 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 7/28/22, the MDS indicated, Resident 14's BIMS score was 0 out of 15 indicating severe cognitive impairment. During a concurrent interview and record review on 9/23/22, at 10:34 a.m., with LVN 1, Resident 14's clinical record was reviewed. LVN 1 stated, Resident 14 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 14 had bed rail use prior to 9/22/22. 10. During an interview on 9/21/22, at 3:21 p.m., with LVN 2, LVN 2 stated she had not had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 20 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in-service training for side rails. LVN 2 stated, it was a nursing measure to have two side rails and there was no requirement to have physician order, consent, or care plan. LVN 2 stated she was unaware of the entrapment risk assessment and had not seen it at the facility. LVN 2 stated she did not recall the last time she had seen the facility policy regarding side rail use. During a concurrent observation and interview on 9/22/22, at 11:52 a.m., with CNA 3, in Resident 1's room, Resident 1 was lying in bed with two bed rails up. CNA 3 stated Resident 1 had two bed rails up which were used for safety to prevent fall. During a review of Resident 15's MDS, dated 8/11/22, the MDS indicated, Resident 1's BIMS score was 0 out of 15 indicating severe cognitive impairment. During an interview on 9/22/22, at 3:18 p.m., with Maintenance (MN), MN stated he did not conduct routine preventative maintenance for bed rails. MN stated he addressed bed rails as needed when facility staff would report an issue. During a concurrent interview and record review on 9/22/22, at 9:43 a.m., with Director of Staff Development/Infection Preventionist (DSD/IP), the facility policy titled, Proper Use of Side Rails, dated 12/2016 was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DSD/IP stated the policy only applied when the bed rails were considered a restraint. DSD/IP reviewed her in-service binders and stated there were no in service training for bed rails. DSD/IP stated the bed rails were used as mobility devices therefore the policy did not pertain when only two bed rails were used. DSD/IP stated there was a risk for entrapment when bed rails were in use. During a concurrent interview and record review on 9/22/22, at 10:01 a.m., with Director of Nursing (DON), the facility policy titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol . DON stated it was the facility policy to include all the components as outlined in the policy prior to bed rail use. DON stated the bed rails were in use for safety but can be a risk for entrapment. DON stated it was the responsibility of Licensed Nurses to develop a care plan for bed rail use to maintain continuity of care. During an interview on 9/22/22, at 11:56 a.m., with DON, the DON stated the Interdisciplinary Team (IDT) consisted of multidisciplinary staff. The DON stated the IDT meetings were held daily except for weekends. DON stated she did not recall when or if bed rails were discussed in the IDT meetings. During a concurrent interview and record review on 9/23/22, at 10:29 a.m., with LVN 1, Resident 1's clinical record was reviewed. LVN 1 stated, Resident 1 did not have an entrapment risk assessment in place for bed rails. LVN 1 stated the care plan, consent and physician order was placed on 9/22/22. LVN 1 stated Resident 1 had bed rails use prior to 9/22/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 21 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm During a review of the facility job description titled, Director Of Staff Development undated, was reviewed. The job description indicated, . Participates in Quality Assurance meetings to identify training needs . Provides resources for licensed staff In-services in clinical skills development . Participates as a member of Safety Committee to identify training needs of staff . Participates in Care Plan Conferences to monitor for training needs . Residents Affected - Few During a review of the facility job description titled, Charge Nurse undated, was reviewed. The job description indicated, . The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures . Assist in writing and updating Resident Assessment and Comprehensive Care Plans . During a review of the facility policy and procedure titled, Proper Use of Side Rails, dated 12/2016, was reviewed. The policy indicated, . The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Documentation will indicate if less restrictive approaches are no successful, prior to considering the use of side rail . The risk and benefits of side rails will be considered for each resident . Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefit and risks . The resident will be checked periodically for safety relative to side rail use . When side rail usage Is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being use) . Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions . During a review of professional reference from the FDA- Food and Drug Administration titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-c dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled, or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports, 480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. Feeling isolated or unnecessarily restricted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 22 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 23 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure the Dietary Services Supervisor (DS) possessed the appropriate competencies and skills set to carry out the functions of the food and nutrition services department in accordance with the DS job description when: 1. The DS did not provide the necessary oversight of food safety, sanitation, and storage in the kitchen: 1a. Dietary staff were not implementing or accurately documenting safe food cool down process. 1b. Dietary staff did not label food and did not dispose expired food. 1c. The DS did not have the required certification or education to meet the needs of the DS position. These failures had the potential to place residents who consumed meals prepared from the kitchen to be at risk for foodborne illnesses related to growth of microorganisms (bacteria or fungus that cause nausea, vomiting, and diarrhea), weight loss, and malnutrition. (cross reference F812) Findings: 1a. During an interview on 9/21/22, at 12:09 p.m., with [NAME] 1, [NAME] 1 stated she did not prepare food the day before to cut down time on preparation of meals. [NAME] 1 stated when chicken or tuna salad was the main dish, she prepared it the same day. [NAME] 1 stated the tuna and seasonings were stored in the dry storage area while the rest of the ingredients were stored in the refrigerator. [NAME] 1 stated once all the ingredients were mixed, she placed the salad in the refrigerator and prior to serving the salad, she checked the temperature. [NAME] 1 stated when preparing pudding from powder, she added milk and followed the directions on the package. [NAME] 1 stated once she was done preparing the pudding, she placed the pudding in serving bowls and placed them into the refrigerator and the temperature was checked prior to serving the pudding to the residents. During an interview on 9/21/22, at 3:40 p.m., with [NAME] 2, [NAME] 2 stated when chicken or tuna salad was on the menu, the salad was made the same day. [NAME] 2 stated most of the ingredients were from the refrigerator except for the seasonings. [NAME] 2 stated after she mixed all the ingredients, she labeled and covered the salad and placed it in the refrigerator. [NAME] 2 stated she never checked the temperature prior to placing the salad in the refrigerator but she did check the temperature prior to serving the salad. During an interview on 9/22/22, at 9:30 a.m., with the DS, the DS stated the cool down process started when the food was at 140 degree (°) Fahrenheit (F-unit of measurement) and she had six hours to cool the food to 41°F. The DS stated every two hours the temperature of the food was checked and logged in the Cool Down Log. The DS stated if the temperature was dropping every two hours and by the sixth hour if the temperature was 41°F the cool down process was complete and it did not matter what the temperature was, two hours into the cooling process. During a concurrent observation and interview on 9/22/22, at 10:05 a.m., with the DS, in the walk-in refrigerator, there were several leftovers in containers to include: chicken noodles dated 9/20/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 24 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and used by date 9/23/22, beef dated 9/20/22 and used by date 9/23/22, chicken dated 9/21/22 and used by date 9/24, salad dated 9/21/22 and used by date 9/24/22, corn slaw dated 9/20/22 and used by date 9/23/22 and chicken dated 9/19/22 and used by date 9/22/22. The DS validated the food in the containers were leftovers. During a concurrent interview and record review on 9/22/22, at 10:10 a.m., with the DS, the facility's document Cooling/Chilling Temperature Control Log (Log), dated 12/2021, 1/2022, 2/2022, 3/2022, 4/2022, 5/2022, 6/2022, 7/2022, 8/2022 and 9/2022, and the facility's P&P titled, Food Preparation . Cool Down, dated 2018 was reviewed. The DS stated, the Logs indicated there had not been any entries made for the month of 1/2022, 4/2022, 5/2022, 6/2022, 7/2022, 8/2022 and 9/2022. The DS stated, the 9/2022 Log indicated there were no entries for the leftovers that were in the refrigerator. The DS stated the P&P indicated, . Food that is cooked and will not be used for immediate service will be cooled to the appropriate temperatures within the allotted time to prevent microbial growth [an increase in the number of bacteria] . A cool down log will be maintained to ensure standards are met . Food must be cooled to 70°F within two hours and then to 41°F within the next four hours . During a concurrent interview and record review, on 9/22/22, at 10:18 a.m. with the DS, the Kitchen In-Service Binder, undated was reviewed. The DS stated she had not provided any in-services or education on the Cool Down process since 3/2022, when she became the DS and there had not been any education or in-services logged in the Kitchen In-Service Binder since 1/2021 pertaining to the Cool Down process. The DS stated her expectations were for cooks to prepare everything in the kitchen properly and use the Cooling Logs when appropriate. The DS stated the importance of the cool down process was to make sure the food was properly cooled to prevent bacteria from growing on the food which could cause residents to get sick if they consumed the food that was not cooled down properly. During an interview on 9/23/22, at 1:29 p.m., with the Registered Dietitian (RD), the RD stated kitchen staff should be using the cool down process. The RD stated the importance of using the cool down process was to make sure the food was cooled as quick as possible to prevent the food from staying in the temperature danger zone which was between 41°F to 135°F. The RD stated food that stayed in the temperature danger zone could cause bacterial growth and foodborne illnesses which could be bad for residents. The RD stated her expectations were for kitchen staff to start using the cool down log when food products needed to be cooled. During a review of the facility's P&P titled, Food Preparation . Calibrating and Sanitizing Thermometers, dated 2018, the P&P indicated, . Two Tiered Cooling: Internal temperature of food must be reduced from 140°F to 70°F in 2 hours and cooled from 70°F to 41°F in 4 hours . During a review of the facility document titled, Job Description: Dietary Service Supervisor (DSS), undated, the DSS Job Description indicated, . responsibilities . provide a sanitary and infection free environment . Supervise food preparation and service . Observe for over-production of food and improper preparation of foods . 1b. During an observation on 9/20/22, at 9:12 a.m., in the dry storage area, there were multiple food items or products that did not have used by dates and dates indicating the food product or item were expired. During an interview on 9/22/22, at 10:20 a.m., with the DS, the DS stated the kitchen staff who stocked the dry storage area were responsible for checking expiration dates and labeling of new food products or items. The DS stated the received date and the used by date should be written on all the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 25 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few items in the dry storage area. The DS stated she made sure food items were not expired and everything was labeled appropriately. The DS stated the residents could become ill if they consumed expired food. During an interview on 9/23/22, at 1:30 p.m., with the RD, the RD stated her expectations were for kitchen staff to dispose of expired food items and make sure everything was labeled and dated to prevent wasting of food. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Canned and Dry Goods Storage, dated 2018, the P&P indicated, . All open food items will have an open date and use-by-date per manufacturer's guidelines . new stock must be placed behind the old stock so oldest items will be used first. Products should be dated to assure FIFO-First In-First Out. Food items will be labeled and dated when placed into containers . Bins holding dry goods such as flour, sugar, bean, etc. must be clearly labeled, dated on the lid or front of the container and dated when product was put into bin . During a review of the facility's P&P titled, Food Receiving and Storage, dated 2014, the P&P indicated, . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees Fahrenheit (F-a unit of measurement) must be placed in the refrigerator located at the nurses' station and labeled with a use by date . 1c. During an interview on 9/22/22, at 9:30 a.m., with the DS, the DS stated she had been in her position as the Dietary Services Supervisor (DS) since March 2022. The DS stated she had been a cook prior to taking on her new role as the DS. The DS stated she did not have the training to be a DS but was trained by the previous DS on the basic stuff and there was no documentation of her training by the previous DS. The DS stated her training may have been 30 hours of hands-on training with the previous DS. The DS stated she was not sure what certifications or training she needed to be a DS. During an interview on 9/23/22, at 1:35 p.m., with the RD, the RD stated the DS should have certified dietary manager training because there was no full time RD at the facility. The RD stated she was aware the DS had not completed the required training to be a DS. The RD stated due to the DS not being trained appropriately, she could potentially expose the residents in the facility to food borne illnesses and potential weight loss. The RD stated her expectations for the DS was to start looking for programs and start working her way to becoming certified. During a review of the DS's Employee File, undated, the Employee File indicated, the DS had an American National Standards Institute (ANSI) eFoodHandler Basic Safety Course issued on 11/3/2020 and expiration date of 11/3/2023. The Employee File indicated, the DS did not have any other certifications. During an interview on 9/23/22, at 5:27 p.m., with the Administrator (ADM), the ADM stated she was aware the DS did not have the qualifications to be a DS. The ADM stated the DS had a brief orientation with the previous DS. The ADM stated the residents could lose weight if the therapeutic diets ordered by the physician were not followed through and the residents could potentially be exposed to food borne illnesses because the DS was not certified. The ADM stated her expectations of the DS were to check new admissions, make recommendations, oversee residents' health and nutrition, provide in-services on infection control and safety in the kitchen, and labeling of food products which had been an ongoing problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 26 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm During a review of DS's Competency Checklist for Employee for Department of Nutrition and Food Services (Competency), dated 5/28, the Competency indicated the DS needed improvement on the topic of Temperature Danger Zone: 39-140 degrees Fahrenheit. The Competency indicated the DS did not have the Orientation, Inservice, & Personnel Management . Job Skills Evaluation, signed off by herself or the previous DS. Residents Affected - Few During a review of the facility document titled, Job Description: Dietary Service Supervisor (DSS), undated, the DSS Job Description indicated, . Education: Graduation from a course in food service supervision which meets the standards established by the American Dietetic Association or a graduate of another course in food service supervision with 90 or more hours in classroom instruction with on-the-job counseling by a dietitian . knowledge of and ability to meet regulations of ADA [Americans with Disabilities Act], state, infection control, health department, and OSHA [Occupational Safety and Health Administration] . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 27 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety when: Residents Affected - Many 1. Food products stored in the dry storage area and refrigerator contained food items that were not labeled and dated and discarded on or before the expiration dates. 2. Shelled eggs prepared for residents were not pasteurized eggs. 3. Kitchen staff did not follow the facility's policy for Cool Down. These failures placed residents at risk for foodborne illness and food contamination. Findings: 1. During a concurrent observation and interview on 9/20/22, at 9:01 a.m., with the Dietary Supervisor (DS), in a refrigerator in the kitchen, there were two diet cakes in circular pans with a label adhered to the plastic covering on each cake, and there were no dates written on the label. The DS stated, I made those cakes last night, I put the labels on the cakes but forgot to write down the date. During an observation on 9/20/22, at 9:07 a.m., in the kitchen, there were five clear bins filled with assorted dry goods. The bins were labeled with: flour, received date: 2/4/22, opened date: 2/4/22 and used by date: 2/4/23; pinto beans, received date: 4/2/22 and no used by date; rice, opened: 8/25/22 and used by date: 8/23; sugar, 8/22 and no used by date; and thickener, dated: 8/25/22 with used by date: 8/23. During a concurrent observation and interview on 9/20/22, at 9:12 a.m., with the DS, in the dry storage area, there were dry goods that had expired dates and some food products did not have all the components labeled on each food product to include the received date, opened date, and used by date. This list included: Brand Name pretzels received on 2/25/22 on the plastic container, inside the plastic container was a resealable plastic bag with pretzels inside dated 5/11/22 and no used by date; Bread Crumbs in a resealable plastic bag with received date of 7/30/21 and no used by date; A container of Ground Cumin with no labeling; Four containers of Italian Seasoning with no labeling; Four containers of Dill Weed with received date of 7/2/21 and used by date of 7/2/22; Diet Jello Powder packets in a plastic bin labeled received date of 9/2021 and no used by date; Assorted Gelatin packets in a plastic bin labeled opened on 3/19/21 and used by date of 3/19/22; Lemon Instant Pudding & Pie filling mix packets is in a plastic bin, but label reads Chocolate & Vanilla Pudding with received date of 10/2/21 and another date 11/3/21; Tapioca Pudding packets in a plastic bin labeled with received date of 8/5/21 and used by date of 8/5/22; and Box with a bag of prunes labeled opened on 7/1/22 and used by 8/8/22. The DS stated the containers of Ground Cumin, Italian Seasoning, and Dill weed needed to be thrown out and was observed getting placed in the trash receptacle. During an interview on 9/22/22, at 10:15 a.m., with the DS, the DS stated, kitchen staff who were stocking the dry storage area were responsible for checking the expirations dates and labeling of food products. The DS stated, the received date and the used by date should be written on all the items in the dry goods storage area. The DS stated the importance of labeling food products was to use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 28 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the food products before the expiration date. The DS stated, residents could become ill if they consumed expired food. The DS stated from now on she would make sure food products were not expired and everything was labeled appropriately by checking the dry storage area on Fridays when stocking was completed. During an interview on 9/23/22, at 10:24 a.m., with the Registered Dietitian (RD), the RD stated her first time at the facility was on 9/13/22. The RD stated she toured the kitchen and found spices past their used by date and the DS was supposed to dispose of the expired spices and order new spices. During an interview on 9/23/22, at 1:30 p.m., with the RD, the RD stated the DS should have ordered new spices and should have disposed the expired spices. The RD stated most of the residents in the facility were immunocompromised (the immune system's defense are low, affecting its ability to fight off infections and diseases) due to their age and pre-existing conditions, which placed the residents at a higher risk to develop food borne illnesses especially if they consumed food past their expiration date. The RD stated the DS should ensure all food products were labeled. The RD stated the kitchen staff should label all food items and products with the received date and when a food item or product was opened, kitchen staff should label the food items with an open date and a used by date. The RD stated it was important to ensure all food items and products were labeled with the date it was received, when it was opened, and a used by date for kitchen staff to be made aware when a food item was about to expire to prevent wasting food. The RD stated kitchen staff should practice the First In First Out (FIFO) method and to use the food items or products that were going to expire first then the newer food items that were just delivered. The RD stated, her expectations were for kitchen staff to continue to carry out and improve the process of labeling, dating, and disposing of expired food products. During a concurrent observation and interview on 9/23/22, at 2:05 p.m., with Licensed Vocational Nurse (LVN) 1, in the medication room where the resident snack refrigerator was located, three of 12 assorted juices were not labeled with a date and there was a sandwich with a date and no used by date was observed. LVN 1 stated there were some juices without dates in the refrigerator and the sandwich should have a used by date which was usually three days from the opened date. LVN 1 stated Licenses Nurses (LN) were responsible for checking the food items in the refrigerator and was usually done at night on the NOC (a period of time during the night in which a person is scheduled to work) shift which was from 10:30 p.m. to 7 a.m. LVN 1 stated the kitchen staff should be labeling the dates on food items in the refrigerator. LVN 1 stated the importance of labeling was to let everybody know if the food product was about to expire or if it was expired. LVN 1 stated residents could become ill if they consumed expired food products. During an interview on 9/23/22, at 5:27 p.m., with the Administrator (ADM), the ADM stated her expectations were for the DS to oversee the labeling of food products which has been an ongoing problem. The ADM stated the facility was ensuring labeling was done by having the DS check as well as the Director of Staff Development (DSD) perform a walkthrough of the kitchen to see if anything was forgotten or not completed. The ADM stated the cooks were also responsible for labeling, dating, and checking for expiration dates and to use the first in first out method to prevent wasting of food products. During a review of the facility document titled, Job Description: Dietary Service Supervisor (DSS), undated, the DSS Job Description indicated, . responsibilities . provide a sanitary and infection free environment . supervise the receiving and storage of food . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 29 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Canned and Dry Goods Storage, dated 2018, the P&P indicated, . All open food items will have an open date and use-by-date per manufacturer's guidelines . new stock must be placed behind the old stock so oldest items will be used first. Products should be dated to assure FIFO-First In-First Out. Food items will be labeled and dated when placed into containers . Bins holding dry goods such as flour, sugar, bean, etc. must be clearly labeled, dated on the lid or front of the container and dated when product was put into bin . During a review of the facility's P&P titled, Food Receiving and Storage, dated 2014, the P&P indicated, . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees Fahrenheit (F-a unit of measurement) must be placed in the refrigerator located at the nurses' station and labeled with a use by date . 2. During an interview on 9/21/22, at 10:26 a.m., with [NAME] 1, [NAME] 1 stated shell eggs were used for fried eggs that morning. [NAME] 1 stated all the fried eggs were fully cooked and over easy or runny eggs were not served to residents. During an interview on 9/21/22, at 3:40 p.m., with [NAME] 2, [NAME] 2 stated the fried eggs served to residents were fully cooked and she ensured the eggs were fully cooked by checking the temperature of the eggs which should be 155°F . [NAME] 2 stated the eggs used for fried eggs were shell eggs and she knew they are pasteurized eggs by the P stamped on the eggs. During an interview on 9/22/22, at 9:23 a.m., with [NAME] 1, [NAME] 1 stated she knew the eggs were fully cooked when she checked the temperature, and the temperature was 155°F or higher. [NAME] 1 stated she knew the eggs were pasteurized by looking at the box the eggs came in which stated the eggs were pasteurized. During a review of the facility's menu Good For Your Health Menus, dated 9/19-25/22, the menu indicated on 9/21/22, fried eggs was served for breakfast. During a concurrent observation and interview on 9/22/22, at 9:30 a.m., with the DS, in the walk-in refrigerator, a box of eggs was observed, and the DS stated the box did not indicate the eggs were pasteurized. The DS stated she knew the eggs she purchased were pasteurized because her order stated the eggs ordered were pasteurized eggs. The DS stated she did not know why eggs had to be pasteurized. During an interview on 9/22/22, at 12:10 p.m., with Resident 2, Resident 2 stated he preferred his fried eggs over easy and that was how he ordered his eggs. During a concurrent interview and record review on 9/22/22, at 3:31 p.m., with the DS, the facility's invoice titled, Customer's Original Invoice Confidential Property of Sysco, dated 9/9/22 and the website titled, shop.sysco.com, undated was reviewed. The invoice indicated, three cases of 15 dozen WHLFIMP EGG SHELL MED WHT AA was purchased by the facility. The DS stated, the invoice did not indicate the eggs purchased were pasteurized eggs. The DS stated the website where the eggs were purchased did not indicate the eggs were pasteurized eggs. The DS stated, the website indicated pasteurized eggs had a P stamped on the eggshell, verifying the eggs were pasteurized eggs. The DS stated now that she knew the website carried pasteurized eggs, moving forward she would start purchasing pasteurized eggs instead of the unpasteurized eggs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 30 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 9/23/22, at 1:25 p.m., with the RD, the RD stated the importance of using pasteurized eggs in long term care facilities was to prevent foodborne illnesses to the immunocompromised population who resided at the facility. The RD stated her expectations of the facility was to use and purchase pasteurized eggs from now on and she would ensure the DS was educated on the importance of pasteurized eggs and following through with purchasing pasteurized eggs. Residents Affected - Many During an interview on 9/23/22, at 5:27 p.m., with the ADM, the ADM stated the use of pasteurized eggs were safer for the residents than unpasteurized eggs and therefore, the facility should be using pasteurized eggs. The ADM stated her expectations were for the facility to use pasteurized eggs based on the recommendations of the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA). During a review of the facility's P&P titled, Food Preparation . Food Cookery, dated 2018, the P&P indicated, . Pasteurized eggs (shelled or liquid) must be used . During a professional review of the Centers for Medicare and Medicaid Services guidance titled, Advance Copy of Revised F371; Interpretive guidance and Procedures for Sanitary Conditions, Preparation of Eggs in Nursing Homes, dated 5/20/14, the guidance indicated, . Skilled nursing and nursing facilities should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritidis [(SE)-a common cause of food poisoning]. The use of pasteurized eggs allows for resident preference for soft-cooked, undercooked or sunny-side up eggs while maintaining food safety . if unpasteurized eggs contaminated with SE are eaten raw or undercooked the bacterium [bacteria] can cause illness and death particularly in the elderly, infants, and those with impaired immune systems . 3. During an interview on 9/21/22, at 10:39 a.m., with the DS, the DS stated there was usually no leftovers, so the facility did not need to use the cool down log. During an interview on 9/21/22, at 12:09 p.m., with [NAME] 1, [NAME] 1 stated she did not cook food a day ahead, instead she prepared chicken or tuna salad the same day if it was a main dish. [NAME] 1 stated the tuna and spices were stored in the dry goods storage area and the rest of the ingredients were from the refrigerator. [NAME] 1 stated after preparing the salad, she placed the salad in the refrigerator and checked the temperature prior to serving the salad. [NAME] 1 stated when she prepared pudding from powder form, she followed the directions on the package and as soon as the pudding was prepared, she poured them into individual serving bowls, covered the bowls, placed them in the refrigerator and the temperature was checked before serving to residents. During an interview on 9/21/22, at 12:18 p.m., with [NAME] 2, [NAME] 2 stated when she prepared dinner, she made just enough food so there were no leftovers. [NAME] 2 stated she would use the cool down process for the leftover spaghetti from lunch by placing the spaghetti into smaller containers, label with the date, kept the containers on the counter for a couple hours or sometimes she would use ice to help cool the food down then placed it in the refrigerator. [NAME] 2 stated she would check the temperature before placing the spaghetti inside the refrigerator and it could be used for up to 3 days. During an interview on 9/21/22, at 3:40 p.m., with [NAME] 2, [NAME] 2 stated the temperature of the spaghetti should be 40°F before she placed it in the refrigerator. [NAME] 2 stated when chicken or tuna salad was on the menu, the salad was made the same day. [NAME] 2 stated most of the ingredients were from the refrigerator except the seasonings. [NAME] 2 stated after she mixed all the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 31 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many ingredients, she would label the salad, cover it, and then placed the salad in the refrigerator. [NAME] 2 stated she never checked the temperature before placing the salad into the refrigerator, but she did check the temperature prior to serving the salad. During an interview on 9/22/22, at 9:23 a.m., with [NAME] 1, [NAME] 1 stated she started the cool down process by placing food items in a bag or smaller container then placed it on top of an ice bath, let it sit and check the temperature every two hours, the first temperature should be 138°F or below, next temperature in two hours should be 41°F or below and she has six hours total for the food item to be 41°F or below. During an interview on 9/22/22, at 9:30 a.m., with the DS, the DS stated she started the cool down process when the temperature of the food items reached 140°F and she had six hours to cool the food down to 41°F. The DS stated every two hours she would check the temperature and log the temperature on the Cool Down log. The DS stated the temperature should be dropping from 140°F, if the temperature was dropping every two hours and by the sixth hour if the temperature was 41°F, then she had completed the Cool Down process and at that time she would place the food item in the refrigerator. During a concurrent observation and interview on 9/22/22, at 10:05 a.m., with the DS, in the walk-in refrigerator, there were several leftovers in containers to include: chicken noodles dated 9/20/22 and used by date 9/23/22, beef dated 9/20/22 and used by date 9/23/22, chicken dated 9/21/22 and used by date 9/24, salad dated 9/21/22 and used by date 9/24/22, corn slaw dated 9/20/22 and used by date 9/23/22 and chicken dated 9/19/22 and used by date 9/22/22. The DS validated the food in the containers were leftovers. During a concurrent interview and record review on 9/22/22, at 10:10 a.m., with the DS, the facility's document Cooling/Chilling Temperature Control Log (Log), dated 12/21, 1/22, 2/22, 3/22, 4/22, 5/22, 6/22, 7/22, 8/22 and 9/22, and the facility's P&P titled, Food Preparation . Cool Down, dated 2018 was reviewed. The DS stated, the Logs indicated there had not been any entries made for the month of 1/22, 4/22, 5/22, 6/22, 7/22, 8/22 and 9/22. The DS stated the P&P indicated, . Food that is cooked and will not be used for immediate service will be cooled to the appropriate temperatures within the allotted time to prevent microbial growth [an increase in the number of bacteria] . A cool down log will be maintained to ensure standards are met . Food must be cooled to 70°F within two hours and then to 41°F within the next four hours . During a concurrent interview and record review, on 9/22/22, at 10:18 a.m. with the DS, the Kitchen In-Service Binder, undated was reviewed. The DS stated she had not provided any in-services or education on the Cool Down process since 3/2022 , when she became the DS and there had not been any education or in-services logged in the Kitchen In-Service Binder since 1/2021 pertaining to the Cool Down process. The DS stated her expectations were for cooks to prepare everything in the kitchen properly and use the Cooling Logs when appropriate. The DS stated the importance of the cool down process was to make sure the food was properly cooled to prevent bacteria from growing on the food which could cause residents to get sick if they consumed the food that was not cooled down properly. During an interview on 9/23/22, at 1:29 p.m., with the RD, the RD stated kitchen staff should be using the cool down process. The RD stated the importance of using the cool down process was to make sure the food was cooled as quick as possible to prevent the food from staying in the temperature danger zone which was between 41°F to 135°F. The RD stated food that stayed in the temperature danger zone could cause bacterial growth and foodborne illnesses which could be bad for residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 32 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The RD stated her expectations were for kitchen staff to start using the cool down log. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Food Preparation . Hazard Analysis of Critical Control Points (HACCP) for Food Preparation, dated 2018, the P&P indicated, . Each facility should develop HACCP procedures to assure that foods produced and consumed will be safe . Food Handling and Preparation-Do the employees have directions for handling, storing and reheating leftovers? Are temperature control logs being utilized for potentially hazardous foods? Are prepared foods monitored throughout the day for time and temperature? . Residents Affected - Many During a review of the facility's P&P titled, Food Preparation . Calibrating and Sanitizing Thermometers, dated 2018, the P&P indicated, . Two Tiered Cooling: Internal temperature of food must be reduced from 140°F to 70°F in 2 hours and cooled from 70°F to 4°F in 4 hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 33 of 33