Health inspection·August 28, 2024

F 0625 the BOM of Resident 1 ' s transfer. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 8/6/24 at 12:06 p.m. with the Business Office Manager (BOM), the BOM stated Resident 1 ' s RP signed the Bed-hold policy on admission. Resident 1 ' s [name of SNF] Bed Hold Policy, signed by the RP on 6/28/24, was reviewed. The policy indicated, . California Law requires . to hold a bed for up to seven (7) days for any Resident who is transferred to a General Acute Care Hospital (GACH). This is known as a Bed Hold. If the Resident ' s care is paid under the Medi-Cal program, Medi-Cal will pay for up to seven (7) day bed hold period . The BOM stated it was the family ' s responsibility to contact the facility for a Bed-hold when a resident was transferred. The BOM stated she made a courtesy call to the resident ' s RP and notified the RP they would need to pay for the Bed-hold. Resident 1 ' s progress note dated 7/18/24, at 10:22 a.m. indicated, . Late entry: Called resident ' s wife . no answer, unable to leave message. Discussed with the DON Re: [regarding] BH [bed hold] & re-admission in question since no medical [Medi-Cal] eligibility in place and for Medicare eligibility, resident has a Manage[d] Medicare Advantage Plan . The BOM stated since the Bed-hold was not paid for by the family or Medi-Cal, she had discharged Resident 1 from the facility on 7/11/24. Residents Affected - Few During a telephone interview on 8/19/24 at 1:26 p.m. with the BOM, the BOM stated when Resident 1 was transferred to the hospital, the facility does not provide a written Bed-hold notice to residents. The BOM stated the facility ' s process was to provide a written Bed-hold policy during admission on ly and if a resident was transferred after admission, the notice was provided by phone. During a review of the facility ' s policy and procedure (P&P) titled Transfer and Discharge Requirements, undated, the P&P indicated, . It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident unless condition or circumstances warrant . One of the following reasons must be noted in the clinical record of all transferred or discharged residents . The transfer or discharge is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility . safety of individuals in the facility is endangered . health of individuals in the facility is endangered . The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility . Written notice of the discharge or transfer must be given to the resident and, if known, legal representative or family member . During an interview on 8/27/24 at 3:31 p.m. the facility ' s P&P titled Transfer and Discharge Requirements was reviewed. The ADM stated the facility has residents/RPs sign a written bed hold policy on admission but does not provide a written Bed-hold policy when transferred to the ACH. The ADM stated Resident 1 ' s RP was not provided a written Bed-hold notice when he transferred to the ACH. The ADM stated, I don ' t know if the P&P was followed. During a review of the facility ' s P&P titled Bed Hold: Medical Record Readmission/Closure Policy, undated, the P&P indicated, . This policy applies irrespective as to whether a bed-hold applies . At time of transfer out . The Notice of Transfer/Discharge form and the Bed Hold Policy form must be complete . During a review of Federal Regulations for Transfer and Discharge, the regulations indicated, . Notice of Bed-Hold Policy . All facility must have policies that address holding a resident ' s bed during periods of absence, such as during hospitalization . facilities must provide written information about these policies to residents prior to and upon transfer . This information must be provided to all facility residents, regardless of their payment source . These provisions require facilities to issue two notices related to bed-hold policies . first notice could be given well in advance of any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 2 of 7 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 08/28/2024 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 0625 transfer . second notice must be provided to the resident, and if applicable the resident ' s representative, at the time of transfer, or in cases of emergency transfer within 24 hours . 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 3 of 7 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 08/28/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were hospitalized were permitted to return to the facility for one of three sampled residents (Resident 1) when the facility refused to take Resident 1 back after Resident 1 was medically cleared (when a patient no longer needs to receive inpatient care) to return to the facility from the acute care hospital (ACH). This failure placed Resident 1 at risk for psychosocial harm by not allowing the resident to return to the skilled nursing facility (SNF) near his home and caused him to be transferred to a SNF in a different city. This caused a hardship for Resident 1 ' s spouse when she had to decrease the frequency of her visits to the resident. (Cross reference F625) Findings: During a telephone interview on [DATE] at 3:13 p.m. with Resident 1 ' s family member (FM) 1, FM 1 stated Resident 1 was transferred from the skilled nursing facility (SNF) to the ACH on [DATE]. FM 1 stated the ACH had notified the responsible party (RP) they were ready to discharge Resident 1 back to the SNF on [DATE] and the SNF had refused to accept the resident. FM 1 stated the facility would not provide a clear answer why they refused to allow the resident to return. FM 1 stated the facility was close to Resident 1 ' s home and moving the resident to a facility in another city created a hardship for the family and placed stress on the resident due to diagnosis of dementia (loss in function of thinking, remembering, and reasoning interfering with daily life) and confusion. FM 1 stated Resident 1 ' s spouse was unable to visit the resident as often. During an interview on [DATE] at 10:20 a.m. with the Administrator (ADM) and Director of Nursing (DON), the DON stated Resident 1 was admitted to the SNF on [DATE] and transferred to the ACH on [DATE] for diabetic ketoacidosis (DKA-serious and potentially life-threatening complication of diabetes [disease in which the body does not control the amount of blood sugar in the blood]). The ADM stated Resident 1 was not allowed to return to the SNF because he was private pay and had not paid the bill. The ADM stated Resident 1 ' s seven-day Bed-hold had expired. The ADM stated Resident 1 was also not allowed to return because he had behaviors the facility considered dangerous to the other residents. During a review of Resident 1 ' s admission Record (AR), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of Type 2 diabetes mellitus with ketoacidosis, dementia with behavioral disturbance (disruptive behavior) and malignant neoplasm (cancerous tumor) of the colon (longest part of the large intestine). During a concurrent interview and record review on [DATE] at 11:20 a.m. with LVN 1, Resident 1 ' s Nurse ' s Note (NN), dated [DATE] at 10:11 a.m. was reviewed. The NN indicated, . Resident appeared clammy and noted with labored breathing. Resident was unable to be aroused with verbal or physical stimuli . BS [blood sugar] 446 . [name of physician] notified via phone and gave order to send to [name of ACH] ER [emergency department] . LVN 1 stated Resident 1 ' s blood sugar results while in the facility ranged between 125 and 450 prior to hospitalization. LVN 1 stated Resident 1 ' s medication had been adjusted as needed to control his blood sugar. Resident 1 ' s MAR dated 7/2024 for behavior monitoring was reviewed and indicated Resident 1 had 10 behaviors on [DATE], one behavior on [DATE], and one behavior on [DATE]. LVN 1 stated Resident 1 ' s behaviors mostly consisted of yelling and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 4 of 7 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 08/28/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not place other residents in danger. LVN 1 stated the facility was able to provide the necessary care to other residents with diabetes and/or behaviors. LVN 1 stated she was not sure why Resident 1 was not allowed to return to the facility but was told there were issues with billing. During an interview and record review on [DATE] at 11:43 a.m. with Social Services (SS), SS stated after Resident 1 was transferred to the ACH she received a phone call from Resident 1 ' s (responsible party) RP requesting a Bed-hold. SS reviewed Resident 1 ' s electronic medical record (EMR) and was unable to locate any documentation regarding her conversation with the RP. SS stated Resident 1 ' s wife did not agree to pay for a Bed-hold, and she had told the RP to follow up with the Business Office Manager (BOM). SS stated the facility held an Interdisciplinary Team (IDT-) meeting on [DATE] to discuss Resident 1 ' s return and the IDT had determined the resident required a higher level of care. SS was unable to clarify if Resident 1 was discharged due to the Bed-hold expiring or needing a higher level of care. SS responded, I believe it was both. SS stated Resident 1 required total care and had behaviors which also contributed to the resident to returning to the SNF. SS stated there were other residents in the facility who had behaviors and the facility provided care to them. During a concurrent interview and record review on [DATE] at 12:06 p.m. with the Business Office Manager (BOM), the BOM stated Resident 1 ' s RP signed the Bed-hold policy on admission. Resident 1 ' s [name of SNF] Bed Hold Policy, signed by the RP on [DATE], was reviewed. The policy indicated, . California Law requires . to hold a bed for up to seven (7) days for any Resident who is transferred to a General Acute Care Hospital (GACH). This is known as a Bed Hold. If the Resident ' s care is paid under the Medi-Cal [public health insurance program] program, Medi-Cal will pay for up to seven (7) day bed hold period . The BOM stated it was the family ' s responsibility to contact the facility for a Bed-hold when a resident was transferred. The BOM stated she made a courtesy call to Resident 1 ' s RP and notified the RP they would need to pay for a Bed-hold. Resident 1 ' s progress note dated [DATE], at 10:22 a.m. indicated, . Late entry: Called resident ' s wife . no answer, unable to leave message. Discussed with the DON Re: [regarding] BH [bed hold] & re-admission in question since no medical [Medi-Cal] eligibility in place and for Medicare [eligibility, resident has a Manage[d] Medicare Advantage Plan . The BOM stated since the Bed-hold was not paid for by the family or Medi-Cal, she had discharged Resident 1 from the facility when he was transferred to the hospital on [DATE]. The BOM stated the SNF was responsible to take their residents back after hospitalization. During an interview on [DATE] at 12:31 p.m. with the DON, the DON stated Resident 1 was transferred to the ACH because his blood sugar was out of control. Resident 1 ' s Interdisciplinary Team (IDT) note dated [DATE], at 9:48 a.m. was reviewed. The IDT note indicated, . IDT team met to discuss resident possibly returning to the facility after acute [ACH] stay. It appears resident needs a higher level of care then [than] the facility is able to provide, and readmission isn ' t possible at this time . The DON stated it was the facility ' s responsibility to allow residents to return after they are hospitalized . The DON stated Resident 1 needed a higher level of care because she was worried, he would go into a diabetic coma. The DON stated, his blood sugars were sporadic, kept shooting up to 400. The DON stated Resident 1 ' s blood sugar was scary for us. The DON stated, we usually have no problem taking residents back. If they have a condition we can manage, we do take [them] back. The DON stated the facility had other diabetics they were able to care for. The DON stated Resident 1 had behaviors, but they were not the reason he was not allowed to return. During a telephone interview on [DATE] at 2:55 p.m. with the RP, the RP stated the day after Resident 1 was admitted to the ACH she spoke with SS and was told Resident 1 ' s bed was placed on hold. The RP stated the BOM called her the next day on [DATE] and asked if she had Resident 1 ' s Medi-Cal number but did not notify her they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 5 of 7 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 08/28/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm had not placed the resident ' s bed on Bed-hold. The RP stated on [DATE] the ACH case manager called to notify her Resident 1 was ready for discharge, but the facility would not allow him to return. During a review of Resident 1 ' s ACH document titled Face Sheet, dated [DATE], the FS indicated, . Coverage Information . 1. [name of Medicare plan] . 2. Medi-Cal/Medi-Cal Share of Cost . Residents Affected - Few During a review of Resident 1 ' s Financial Arrangements, dated [DATE], the document indicated, . Beginning on [DATE] . we will provide routine nursing and emergency care and other services to you in exchange for payment . At the time of admission, payment for the care we provide to you will be made by . Resident (Private Pay) [checked] . Medi-Cal [checked] . During a telephone interview on [DATE] at 1:42 p.m. with SS, SS stated She had checked the box for Medi-Cal on the Financial Arrangements because the family had stated Resident 1 had Medi-Cal. SS stated Resident 1 ' s bed was not placed on hold because the family had not provided the Medi-Cal information. During an interview on [DATE] at 3:31 p.m. with the ADM, the ADM the federal regulations indicate if the facility was able to provide care for the resident, they had to allow the resident to return. The ADM stated the DON had decided the Resident needed a level of care the facility could not provide. During a review of Resident 1 ' s ACH document titled Initial Care Coordination Note, dated [DATE], the note indicated, . Expected Discharge Disposition . Skilled Nursing Facility . Patient/Family Goals . Wife want[s] pt [patient] placed in LTC [long term care] . Has recently been at [name of SNF] for rehab to LTC but the facility is not willing to accept him back . During a review of Resident 1 ' s ACH document titled ED to Hosp [hospital]-Admission, dated [DATE], the document indicated, . Assessment and plan . Altered level of consciousness . Septic shock present on admission . Diabetic ketoacidosis . Urinary tract infection . Plan Admit to ICU . During a review of Resident 1 ' s ACH document titled Initial Care Coordination Note, dated [DATE], the note indicated, . Expected discharge date : [DATE] . Patient/Family Goals: Back to [name of SNF] . During a review of Resident 1 ' s ACH document titled Initial Care Coordination Note, dated [DATE], the note indicated, . Known to CM [case manager] d/t [due to] prior admissions. Has recently been at [name of SNF] for rehab to LTC [long term care] butt [sic] the facility is not willing to accept him back . During a review of the facility ' s policy and procedure (P&P) titled, Bed Hold: Medical Record Readmission/Closure Policy, undated, the P&P indicated, . This policy applies irrespective as to whether a bed-hold applies . There may be times that it would be better served to close a record of a resident on bed hold irrespective of whether a resident is on a bed hold or not. This addendum allows a chart to be closed and new record reopened on re-entry on a case-by-case basis with the review of the Director of Nursing Services . The record of a resident transferred/discharged to an acute care facility may be closed and completed as a discharged record if the resident does not return to the facility within: [left blank] days or [left blank] days of transfer/discharge to an acute care facility . At time of transfer out . The transfer order from the physician will include the reason for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 6 of 7 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 08/28/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete transfer . The transfer form will be completed, including resident specific information current on transfer . The transfer form and the licensed nurse ' s note will contain the specific reason for transfer . During a review of the facility ' s P&P titled, Transfer and Discharge Requirements, undated, the P&P indicated, . Transfer and discharge includes movement of a resident to a bed outside of the certified facility . One of the following reasons must be noted in the clinical record of all transferred or discharged residents . Transfer or discharge is necessary for the resident ' s welfare and the resident ' s needs cannot be met in the facility . transfer or discharge is appropriate because the Resident ' s health has improved . safety of individuals in the facility is endangered . health of individuals in the facility is endangered . the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility . facility ceases to operate . Event ID: Facility ID: 555758 If continuation sheet Page 7 of 7