Health inspection·October 7, 2024

F 0801 items should not have been in the kitchen. DA 1 stated the items could have cross contaminated the food. Level of Harm - Minimal harm or potential for actual harm During an observation on 10/7/24 at 10:58 a.m. with DA 2, DA 2 had loose hair hanging out of the hair restraint above her ears. Residents Affected - Many During an interview on 10/7/24 at 11:15 a.m. with the AC, the AC stated the FNS staff needed a full-time supervisor for oversight of the kitchen. During an interview on 10/7/24 at 12:31 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Infection Preventionist for the facility. LVN 1 stated she would do audits weekly in the kitchen to monitor for cleanliness and expired food products. LVN 1 stated the DSS was not full time at the facility, and she was not sure what the regulations were for the hours of FNS oversight. During a concurrent interview and record review on 10/7/24 at 12:50 p.m. with the Payroll Assistant (PA) and Payroll Manager (PM), the RD's time sheets were reviewed. The PA stated the RD was a part time consultant. The RD's time sheets indicated the RD charged 6 hours weekly to the facility. The PM stated the DSS was hired part time on 8/20/23 but had not started as the DSS until 2024. The DSS' time sheets were reviewed and indicated she had worked the following hours every pay period: 6/1/24-6/15/24- 25:15 hours 6/16/24-6/30/24-36:45 hours 7/1/24-7/15/24-33:15 hours 7/16/24-7/31/24-29:00 hours 8/1/24-8/15/24-18:15 hours 8/16/24-8/31/24-37:30 hours 9/1/24-9/15/24-48.45 hours 9/16/24-9/30/24-42.45 hours The PA stated the facility was paid based a 2 week pay period and fulltime employment would be 70-80 hours per pay period. The PA stated the DSS was currently part time. During a telephone interview on 10/7/24 at 4:50 p.m. with the RD, the RD stated she was a consultant and worked for the facility six hours per week. The RD stated she was onsite every other week and remote the opposite weeks. The RD stated the DSS should be full time and part time coverage did not offer proper oversight of the FNS. The RD stated the DSS' duties included ordering the food, verifying staff met competencies, retraining staff as needed, overall discipline and inventory. The RD stated her primary responsibility was to provide overall oversight making sure the DSS was managing FNS. The RD stated she was unaware the DSS was not full time at the facility. During a telephone interview on 10/7/24 at 5:12 p.m. with the DSS, the DSS stated she was working at the facility part time. The DSS stated her duties included scheduling, inventory, monitoring the (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 10/07/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many kitchen, checking food expiration dates, staff training and in-services. The DSS stated the facility should have a full time DSS since the RD was not full time. The DSS stated she tried to be at the facility most days, even if it was only for a couple hours. The DSS stated she had been part time as the DSS since 3/2024. The DSS stated she would need to be at the facility full time fulfill all her job duties. During a review of the FNS Director job description dated 2023, indicated, . Must meet the qualifications of a FNS Director as stated under State & Federal regulations . Duties and Responsibilities . schedule and supervise the Food & Nutrition Services Staff providing in-service training . Is responsible for the preparation and service of all food . Plan kitchen procedure to have food ready on time . Test cooked food by taste to determine if properly cooked and seasoned . maintaining cleanliness of kitchen equipment, and follows all department of health regulations . weekly inventory of food assuring that sufficient supplies are on hand . Make menu adjustments . with final approval of the Facility Registered Dietitian . Maintain resident diet card . Visit residents to determine food acceptance and preferences . responsible for the ordering of food and supplies, checking delivery, supervising storage, signing invoices, and keeping record of food costs . Complete Nutritional Screening form on new residents, MDS and documents all residents quarterly . Review, update, and follow policies & procedures . Attend weight variance meetings . During a review of the facility's job description titled, General Scope of Registered Dietitian's Duties, dated 2023, the job description indicated, . A qualified FNS Director . is responsible for the total operation of the Food & Nutrition Services Department . If a person is not a Registered Dietitian, they must meet the Federal and State laws and receive regular consultation from a Registered Dietitian . Responsibilities of FNS Director . Maintaining acceptable standards of sanitation and food safety . Complete resident dietary profile, nutritional screening, quarterly note, and annual review . Observe residents at mealtime . The Facility Registered Dietitian is a registered member of the Academy of Nutrition and Dietetics, (AND) and is a staff member employed full-time, part-time, or on a consultant basis, depending on the needs of the facility . HSC 1265.4 states a) A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers (continued on next page) 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 10/07/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. Residents Affected - Many 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 10/07/2024 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 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 in accordance with professional standards for food services safety when: Residents Affected - Many 1. The spice storage area contained food products which were not discarded on or before the expiration dates according to facility policies. 2. There was a cart with multiple personal belongings and used items in the kitchen area. 3. Four of four staff did not have their hair properly covered by a hair restraint. These failures placed residents at risk for foodborne illness and contamination. (Cross reference F801) Findings: During an observation on 10/7/24 at 10:44 a.m. with Dietary Aide (DA) 1, DA 1 was in the kitchen and her hair restraint was not covering the hair around her ears, temples, and forehead. During an observation on 10/7/24 at 10:49 a.m. with the Assistant [NAME] (AC), the AC did not have her hair restraint on properly, exposing a large amount of hair above both ears. During a concurrent observation and interview on 10/7/24 at 10:53 a.m. with the AC, a rolling cart was observed in the kitchen, under the office window, next to the handwashing sink. The items on the cart included empty egg cartons, food in plastic resealable bags, personal bags, coffee mugs, water bottles, a pack of chewing gum, paper plates, a jar full of a milky substance and an unmarked jar of a dark fluid. The AC stated the cart with personal items should not be in the kitchen due to potential for cross contamination with the food. The AC pushed the cart out of the kitchen. During a concurrent observation and interview on 10/7/24 at 10:58 a.m. with the [NAME] (CK), the cook had a hair restraint on with hair exposed on all sides of her head. The CK stated she should have her hair completely covered because it could shed and contaminate the food while she was cooking. During an interview on 10/7/24 at 11:06 a.m. with DA 1, DA 1 stated the cart with the personal items should not have been in the kitchen. DA 1 stated the items could have cross contaminated the food. During an observation on 10/7/24 at 10:58 a.m. with DA 2, DA 2 had loose hair hanging out of the hair restraint above her ears. During a concurrent observation, interview and record review on 10/7/24 at 11:15 a.m. with the AC, a bottle of vanilla extract was on the shelf above the preparation table with an open date marked on it of 6/20/2022. The AC walked to the dry storage area and reviewed a spreadsheet of expiration dates and stated the bottle should have been thrown away 6 months after opening. There was a bottle of chili powder on the shelf with an open date of 6/20/22. The AC stated expired food could be contaminated and cause the residents to become ill. The AC stated the FNS staff needed a full-time supervisor for oversight of the kitchen. (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 10/07/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 10/7/24 at 12:31 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Infection Preventionist for the facility. LVN 1 stated she would do audits weekly in the kitchen to monitor for cleanliness and expired food products. LVN 1 stated she had not seen the vanilla extract and chili powder opened in 2022 during her audits. LVN 1 stated expired food products were not safe because they could grow bacteria. LVN 1 stated she was aware of the cart with personal items in the kitchen but thought it was on the far edge of the kitchen, so it was not an issue. During a telephone interview on 10/7/24 at 4:50 p.m. with the RD, the RD stated she works at the facility 6 hours weekly, onsite every other week and remotely on the opposite weeks. The RD stated she was unaware the DSS was not full time. The RD stated less than fulltime coverage by the RD was not proper oversight of the FNS. The RD stated it was important for the DSS to be full time to make sure she was ordering the food, verifying staff meet competencies, retraining staff as needed, overall discipline and inventory. The RD stated her primary responsibility was to provide over all oversight making sure the DSS was managing the FNS. During a telephone interview on 10/7/24 at 4:50 p.m. with the RD, the RD stated she worked for the facility six hours per week. The RD stated she was onsite every other week and remote the opposite weeks. The RD stated she would do a sanitation audit in the kitchen monthly, but she had not seen the vanilla extract and chili powder opened in 2022. The RD stated they should not be in the kitchen available to use. The RD stated they could cause cross contamination and illness. The RD stated hair restraints should be on and covering all hair to prevent physical contamination of the food. The RD stated the DSS should be full time and part time coverage did not offer proper oversight of the FNS. The RD stated the DSS' duties included ordering the food, verifying staff met competencies, retraining staff as needed, overall discipline and inventory. The RD stated her primary responsibility was to provide overall oversight making sure the DSS was managing FNS. During a telephone interview on 10/7/24 at 5:12 p.m. with the DSS, the DSS stated she worked at the facility part time. The DSS stated her duties included scheduling, inventory, monitoring the kitchen, checking food expiration dates, staff training and in-services. The DSS stated she was not aware there were foods on the shelf opened in 2022. The DSS stated they should have been thrown out for the resident's safety. The DSS stated she expected the staff to have the hair restraint covering all hair with none exposed so hair did not fall into the food. The DSS stated the cart with the personal belongings should not be in the kitchen and it had been an ongoing issue. The DSS stated her expectation was for the staff to keep their belongings in the breakroom. The DSS stated the cart could cause cross contamination of the food. During a review of the FNS Director job description dated 2023, indicated, . Must meet the qualifications of a FNS Director as stated under State & Federal regulations . Duties and Responsibilities . schedule and supervise the Food & Nutrition Services Staff providing in-service training . Is responsible for the preparation and service of all food . Plan kitchen procedure to have food ready on time . Test cooked food by taste to determine if properly cooked and seasoned . maintaining cleanliness of kitchen equipment, and follows all department of health regulations . weekly inventory of food assuring that sufficient supplies are on hand . Make menu adjustments . with final approval of the Facility Registered Dietitian . Maintain resident diet card . Visit residents to determine food acceptance and preferences . responsible for the ordering of food and supplies, checking delivery, supervising storage, signing invoices, and keeping record of food costs . Complete Nutritional Screening form on new residents, MDS and documents all residents quarterly . Review, update, and follow policies & procedures . Attend weight variance meetings . (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 10/07/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled Dress Code, dated 2023, the P&P indicated, . Personal Hygiene and appropriate dress are a very important part of the total appearance of the Food * Nutrition Services Department . Proper Dress . Hat for hair, if hair is short, which completely covers the hair . Hair net for hair, if hair is long . If applicable, beards and mustaches (any facial hair) must wear beard restraint . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555758 If continuation sheet Page 7 of 7