Bethany Home Society San Joaquin County

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

a concurrent interview and record review on 9/8/25 at 3:56 PM, Resident 1's Order Summary Report, dated 9/25 and Blood Pressure and Pulse Summary report, dated from 6/20/25 through 9/5/25, was reviewed with the Director of Nursing (DON). The DON stated that the use of the standing lift to transfer Resident 1 was stopped on 7/2/25 not due to episodes of syncope, but due to a right shoulder dislocation (occurs when the ball-shaped top of the upper arm bone separates from the socket-shaped shoulder blade) and right humerus fracture (a break in the bone, located in the upper arm). The DON stated she was unaware that Resident 1 had multiple episodes of syncope, stating that she was only aware of one episode. During a

review of Resident 1's blood pressure and heart rate entries, the DON acknowledged that Resident 1's did have high and low blood pressures and low heart rates that would have indicated a need to hold the Metoprolol, complete orthostatic blood pressures, and to notify the physician, especially if there was a history of syncope during transfers. The DON stated that the lack of further assessment into Resident 1's blood pressure and heart rate fluctuations by the nursing staff placed Resident 1 at risk for continued syncopal episodes which could result in a fall and further injury.During a review of the facility's policy and procedure (P&P) titled, Receiving Physician Medication Orders, dated 11/1/15, the P&P indicated, .Purpose: Clarification of Physician's orders - receiving orders for the medication for abnormal vital signs.B/P: Any abnormal B/P systolic > [greater than] 170 or < [less than] 100 diastolic [bottom number of BP reading] >90 or <40, physician notification is required.If an order is received, b/p parameters are to be included (i.e., Medication given for sbp [systolic blood pressure, top number of BP reading] >170 or hold medication for sbp <100).Pulse: Any abnormal pulse >100 or <60, physician notification is required.If an order is received for any medication, it must include the parameters.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Home Society San Joaquin County

930 West Main Street Ripon, CA 95366

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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that Resident 1 had not been screened by physical therapy when Resident 1 was readmitted from the acute hospital on 7/2/25 with new diagnoses of right shoulder dislocation and right humorous fracture. The DOR further stated that the physical therapist should have screened Resident 1's mobility, reassessed Resident 1's ordered RNP, and provided education to the CNAs and RNAs to ensure they were able to properly place

the right arm immobilizer.During a concurrent interview and record review on 9/5/25 at 3:53 PM, Resident 1's physician order for the immobilizer to the right arm, dated 7/7/25, and Resident 1's RNP order for PROM to the upper and lower extremities three times weekly as tolerated, dated 2/25/20, were reviewed with the Director of Nurses (DON). The DON stated that since the immobilizer was on Resident 1's right arm, the expectation was that the RNAs would know not to perform the PROM exercises or to remove the immobilizer even though Resident 1's RNP order had not been updated upon Resident 1's return from the acute hospital on 7/2/25. The DON further stated that updating the RNP order to exclude PROM to the right upper arm, as well as providing training to the RNA and CNA on removing and placing the immobilizer, techniques in positioning Resident 1's right upper arm during care tasks such as bathing, dressing, bed mobility and transferring to and from her bed and wheelchair should have been done to help reduce the risk of further injury to Resident 1's right upper arm and shoulder.A review of the facility's job description titled, JOB DESCRIPTION RESTORATIVE NURSING ASSISTANT, dated 8/15, the record indicated, .documents

on e-chart [electronic medical record] all activities performed in restorative program and the progress and changes that are observed.A review of the facility's policy and procedure (P&P) titled, RANGE OF MOTION, dated 11/15, the P&P indicated .All residents admitted to [facility name] LTC [long term care] will be screened for current mobility status within 7 days from admission.Residents identified as having a decline in ROM [range of motion] will be referred to PT/TO [physical therapy/occupational therapy] for screening and recommendations.

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