Bethany Home Society San Joaquin County

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards and adequate supervision for 2 of 22 sampled residents (Resident 17 and Resident 22) when:1. A fall (floor) mat remained on the floor next to Resident 17's bed while Resident 17 was up in a wheelchair; and,2. On 7/8/26 Resident 43 approached Resident 22 and touched Resident 22's personal blanket wrapped around her shoulders. Resident 22 then swatted at Resident 43's hand to remove Resident 43's hand, and Resident 43 picked up a box of gloves and hit Resident 22 on the right shoulder with the box of gloves. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement trauma-informed care (a framework that recognizes the widespread impact of trauma and actively avoids re-traumatization) for 1 of 22 sampled residents (Resident 71), when Resident 71's trauma history and trauma triggers were not reassessed and staff failed to collaborate with Resident 71, her family, friends, and/or any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions to avoid re-traumatization after the staff learned that her bed alarm triggered memories of the resident's childhood house fire. This failure resulted in repeated episodes of re-traumatization, fear, emotional distress, anxiety, agitation, and aggressive behaviors for Resident 71.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 37) was free of significant medication errors (one which could jeopardize the residents health and safety) when on 7/4/26, Resident 37 was administered a short acting insulin (insulin, a hormone produced by the pancreas that acts like a key so the body can absorb sugar [glucose] from the blood) instead of a long acting insulin. (Short acting insulin's onset occurs within one hour, peaks between two to four hours and has a duration of action up to eight hours. Long-acting insulin provides a steady, consistent release of insulin into the bloodstream for 24 hours or longer and maintains stable blood sugar levels between meals and overnight). This failure contributed to Resident 37 being sent out to a hospital for treatment and monitoring. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of three residents (Resident 5 and Resident 8) were provided with a safe environment when:1. Resident 5 eloped (a resident leaving the premises or a secure area without authorization, supervision, or the knowledge of the staff) from the facility2. The C Hall exit door did not have an alarm activated during the day3. Resident 5 and Resident 8's [Brand Name] elopement bracelets (bracelet that can be placed on a resident and sets off a door alarm when the resident tries to exit through the door) were not checked at least daily for placement and function and not all exit doors at the facility were alarmed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents' (Resident 1) drug regimen (a structured, prescribed plan for taking medication) was appropriately followed when Resident 1's prescribed narcotic pain medication (a strong, addictive, a regulated pain medication) that was prescribed for moderate to severe pain every six hours, was given without assessing Resident 1's pain level (the numerical pain scale 0 through 10; 0 indicates no pain,1 through 3 indicates mild pain; 4 through 6 indicates moderate pain; 7 through 10 indicates severe pain). This failure had the potential to result in Resident 1 being over-medicated and placed Resident 1 at risk for falls, negatively affecting Resident 1's health and well-being.

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate records for one of two sampled residents (Resident 1) when Resident 1's document titled, Weekly Summary, (a weekly review of the resident's condition) for the week ending in 3/25/226, did not reflect Residents 1's current health status. This failure resulted in an inaccurate representation of Resident 1's current health status and had the potential to negatively impact Resident 1's health regarding wounds and pain management.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe monitoring practices for high-risk medication (drugs with potential to cause harm without monitoring) use in one out of four residents (Resident 1) when:1. Resident 1 was prescribed metoprolol (a medication used to control heart rate and rhythm) without orders to monitor Resident 1's blood pressure or heart rate; and2. Resident 1's experienced syncopal episodes (a brief loss of consciousnesses caused by a temporary decrease in blood flow to the brain) during transfers, which were not adequately documented or addressed by the licensed nurse (LN). These failures had the potential to result in unsafe medication use and adverse consequences for Resident 1.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the restorative nursing program (RNP-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) for one of four sampled residents (Resident 1) when the RNP plan of care for passive range of motion (PROM - the movement of a joint through the range of motion with no effort from the patient) exercises to Resident 1's upper extremities was not revised following a right shoulder dislocation and fracture. This failure placed Resident 1 at risk for further injury, pain and discomfort to the right shoulder and right arm.

Inspectors wroteBased on interview and record review the facility failed to revise a comprehensive elopement (leaving a designated area, often a place of supervision or care, without permission) risk care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to his/her individual needs and goals) for one of two residents at risk for elopement (Resident 1), when Resident 1 was seen by facility staff sitting outside of the building unattended. This failure placed Resident 1 at risk for elopement and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for one of two sampled residents (Resident 1), at risk for elopement (leaving a designated area, often a place of supervision or care, without permission), when Resident 1 was found outside of the physical therapy office back door on 5/27/25 at approximately 5:00 p.m. This failure placed Resident 1 at risk of serious injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation and monitoring of temperature range in one out of one medication refrigerator for a period of 6 months with resident census of 63. This failed practice may have contributed to unsafe storage of refrigerated medication resulting in altered potency and unusable medications based on manufacturer specification.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse for one of sixteen sampled residents (Resident 44) when, Resident 44 was cursed at by Licensed Nurse (LN) 5. This failure had the potential to cause emotional distress and could negatively affect Resident 44's psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs used to control behavior or thought process) for two of five sampled residents (Resident 44 and Resident 52) reviewed for unnecessary medications use when: 1. The physician did not document specific duration for the extended use of the as needed (or PRN) lorazepam (or Ativan, a psychotropic medication for anxiety) beyond 14 days for Resident 52. 2. There was no documented evidence of non-pharmacological interventions (means helping residents with behavioral issue without use of the drugs) for Resident 44 and Resident 52 while taking psychotropic medications for treatment of anxiety. These failures had the potential for unsafe use of psychotropic medications resulting in negative impact or adverse drug effects on Resident 44's and Resident 52's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving regular chicken pot pie received the appropriate nutritive content as prescribed by a physician when serving sizes were smaller than ordered for 19 residents with a census of 63. This failure had the potential of leading to malnutrition and weight loss for the 19 residents receiving a regular diet.

Inspectors wroteBased on interview and record review, the facility failed to notify the Medical Director (MD) in a timely manner with a change of condition for one of 24 sampled residents (Resident 1) when Resident 1 fell and sustained a visible injury and possible non-visible injuries. This failure resulted in the MD not having immediate knowledge of the fall and/or the opportunity to order new treatment which could have provided comfort to Resident 1 and/or prevented his subsequential death.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of three residents sampled (Resident 1) when Resident 1's order to monitor right lower extremity (leg) circulation, motion, and sensation (CMS) was not followed. This failure had the potential for Resident 1 to suffer impairment of the soft tissues and nerves in her right lower extremity which could potentially cause permanent damage to her limb.

Inspectors wroteBased on interview and record review, the facility failed to update one (1) of two resident's (Resident 1) care plan (a document that contains the resident's individualized problems, goals, and interventions) following Resident 1's four elopements (a vulnerable resident who leaves a facility unnoticed) from the facility during the night shift (11:00 PM through 7:00 AM) on 9/30/23. This failure resulted in the facility continuing to utilize ineffective interventions which jeopardized the health and safety of Resident 1, which could have resulted in injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for one (1) of two residents (Resident 1) at risk for elopement (a vulnerable resident who leaves a facility unnoticed) when Resident 1 left the facility four times during the night shift (11:00 PM - 7:00 AM) on 9/30/23 through 10/1/23. This failure jeopardized the health and safety of Resident 1, which could have resulted in injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall intervention for one of two sampled residents (Resident 1) when a fall mat was not placed on the floor while Resident 1 was in bed. This failure had the potential for Resident 1 to sustain further injuries due to a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment for a census of 50 when: 1. Safe water temperatures were not maintained in resident restrooms for 3 out of 5 halls (Hall A, Hall B, and Hall C) in the facility; and, 2. Fall interventions were not implemented for 3 of 21 sampled residents (Resident 22, Resident 23, and Resident 49), when a fall mat was not placed on the floor at bedside for Resident 22, Resident 23, and Resident 49. These failures had the potential to cause physical harm to the residents in the facility.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure high risk medications (with potential to cause harm without careful monitoring) for diabetes (a disease that affect blood sugar) and a blood thinner (could cause bleeding) were monitored for possible adverse effects in two out of 21 sampled residents (Resident 10 and Resident 23). These failures had the potential to affect safe medication monitoring by licensed staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place to monitor psychotropic medications (mind altering drugs) for adverse effects in two out of 21 sampled residents (Resident 11 and Resident 40). These failures had the potential to affect safe medication use and monitoring by licensed staff.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe medication storage practices when: 1. Outdated medication and supplies were stored in the active storage areas in one out of one medication storage room. 2. Emergency kit (or Ekit, a sealed and labeled medication box for emergency use) labeled as Ear and Eye Emergency Kit contained an outdated eye medication in one out of two inspected Ekits. 3. Refrigerated vaccines were stored with food items and the temperature was not monitored twice daily in one out of four medication refrigerators. These failures had potential for medication error and unsafe medication use.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain cleanliness of the ice machine for a census of 50. This failure had the potential for the residents in the facility to receive water and ice with contaminants that could lead to water borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices for a census of 50 residents when: 1. Licensed staff did not perform hand hygiene with hand sanitizer or soap and water while providing care during medication administration for Resident 3 and Resident 25. 2. Medication tray (small tray used to carry medication and supplies into residents' rooms) was not sanitized in-between resident care for Resident 3 and Resident 25. 3. Two direct care staff members did not wear the required personal protective equipment (PPE, includes gowns, gloves, eye protection, facemasks or respirators worn to prevent the spread of germs and infection) when providing care to residents on transmission-based precautions (TBP- infection control precautions for known or suspected infectious agents). [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to: 1. Ensure proper disposition of medication when a container with medications, under a sink, in an unlocked storage room was accessible to anyone for a census of 79. This failure had the potential for staff, visitors, and residents to ingest the medication resulting in an overdose or death. 2. Ensure the medication administration route for bisacodyl suppository (a laxative administered rectally) was specified in the physician's order and medication administration record (MAR) for 17 of 25 sampled residents (Resident 5, Resident 9, Resident 10, Resident 17, Resident 18, Resident 22, Resident 28, Resident 31, Resident 34, Resident 35, Resident 50, Resident 54, Resident 55, Resident 57, Resident 59, Resident 68, and Resident 77). [...]

Inspectors wroteBased on observation, interviews, and facility document review, the facility failed to maintain sanitary conditions during a meal preparation when a kitchen aide entered and walked around the kitchen without her hair being covered for a census of 79. This failure had the potential for food to be contaminated, placing the residents at risk of getting a food borne illness.

Inspectors wroteBased on staff interviews and clinical record review, the facility failed to notify the local Long-Term Care (LTC) Ombudsman (advocate) of the residents' transfer to the local emergency room (ER) for 4 of 41 sampled residents, (Resident 51, Resident 5, Resident 73, and Resident 17). This failure denied Resident 51, Resident 5, Resident 73, and Resident 17 of the added protection of having the LTC Ombudsman being made aware of their transfer from the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure proper storage of and allowed access to chemicals when a liquid drug deactivation container (Brand Name product that uses activated charcoal to neutralize the chemicals in pills, liquids, controlled substances and transdermal patches) was stored on the outside of three medication carts for a census of 79. This failure had the potential for staff, visitors, and residents to ingest the liquid charcoal, resulting in vomiting, and skin or eye irritation.

Inspectors wroteBased on staff interview and document review, the facility did not provide 1 of 3 sampled residents (Resident 75) a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). This failure placed Resident 75 at risk of not being informed of their responsibility to pay for any services received after their Medicare coverage ended.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) for 1 of 41 sampled residents (Resident 68) accurately reflected the resident's functional status (individual's ability to perform activities of daily living [ADLs]). This failure had the potential for Resident 68 to receive inaccurate care.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to implement its infection control program for 6 residents (Resident 12, Resident 34, Resident 36, Resident 40, Resident 41, and Resident 49) out of a census of 79 when staff did not perform proper hand hygiene while assisting residents with meals. This failure had the potential to spread infection to Resident 12, Resident 34, Resident 36, Resident 40, Resident 41, and Resident 49.