Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home Society San Joaquin County during CMS and state inspections, most recent first.
Two residents with documented wandering and elopement risk, one with mild cognitive impairment and visual impairment and another with dementia and osteoporosis, were care planned with branded elopement bracelets but did not have daily checks for device placement and function documented on the MAR/TAR. One resident left a church line, passed through a C Hall exit whose alarm was turned off during the day, entered an independent living area, and was assisted by dietary staff through doors to the outside, later being found in the parking lot by activity staff. The ADM reported that all doors had alarms but that the C Hall alarm was only activated at night and that only the main entrance was tied to the elopement system, while nursing leadership and LNs acknowledged that required daily monitoring and documentation of elopement devices had not been performed.
A resident with dementia and osteoporosis had a standing order for Hydrocodone-Acetaminophen every six hours for moderate to severe pain, but nursing staff administered the narcotic routinely without assessing and documenting the resident’s pain level as required. The MAR showed scheduled Hydrocodone doses given around the clock with no corresponding pain scores, while a separate pain-assessment record reflected only one mild pain score during the same period. In interviews, the LN, ADON, and DON all acknowledged that pain should have been assessed and documented before giving the medication, that the order specified use for moderate to severe pain, and that facility policies required pain assessment each shift and performance and recording of any assessments on which medication administration is conditioned.
A resident with dementia and osteoporosis had a documented MASD-related fissure to the upper gluteal cleft and was receiving Triad cream, scheduled HYDROcodone-Acetaminophen, and later PRN Morphine sulfate for pain, as reflected in progress notes and the MAR. However, the Weekly Summary for that period inaccurately indicated no wounds and no pain, and omitted documentation of the wound, its size, the new skin treatment, and the new pain medication orders or pain episodes. In interviews, the LN acknowledged these omissions, and the ADON and DON confirmed that facility policy and expectations required weekly documentation of skin issues, new treatments, new medications, and pain management on the Weekly Summary, which was not done in this case.
A resident with atrial fibrillation and hypertension was prescribed metoprolol without clear parameters for blood pressure or heart rate monitoring. Abnormal vital signs and multiple syncopal episodes during transfers were not adequately assessed, documented, or communicated to the physician or consultant pharmacist. Nursing staff did not perform orthostatic checks or follow facility policy for abnormal readings, resulting in unsafe medication monitoring practices.
A resident with dementia and a new right shoulder dislocation and fracture did not have their restorative nursing program (RNP) updated to exclude passive range of motion (PROM) exercises to the affected arm, despite physician orders for immobilization. PROM exercises continued as previously ordered, and staff were not trained on immobilizer use or safe handling techniques. The RNP was not reviewed or revised after the resident's hospital readmission, and no referral to physical therapy was made as required by facility policy.
A resident with dementia and other medical conditions, who was unable to complete a mental status interview, was found sitting outside the building unattended. Despite this incident, the care plan identifying the resident as an elopement risk was not revised to reflect the event or update interventions, as confirmed by staff interviews and record review.
A resident with dementia and a high elopement risk was found outside after accessing an unsecured physical therapy office back door. The door lacked an alarm and had been left unlocked by staff, despite the resident's care plan identifying the need for safety measures. Staff interviews confirmed the expectation that therapy room doors remain locked when not in use, but this was not followed, resulting in the resident's unsupervised exit.
A deficiency was identified when a licensed nurse used foul language toward a resident with depression and anxiety, as confirmed by staff interviews and facility documentation. The nurse admitted to telling the resident to "fuck off" during a disagreement, which was corroborated by other staff. Facility policy prohibits such verbal abuse, and the incident was substantiated through investigation.
Failure to Prevent Elopement and Monitor Elopement Devices for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and adequate supervision to prevent elopement for two residents identified as elopement risks. Resident 5 had documented diagnoses including difficulty walking, mild cognitive impairment, and bilateral macular degeneration, and repeated MDS Section E0900 assessments showed wandering behavior occurring 4–6 days in the look‑back periods. Resident 5’s care plan identified the resident as an elopement risk related to frequent exit seeking and impaired safety awareness, with interventions including distraction and use of a branded elopement bracelet on the right ankle. Despite this, on the date of the incident, Resident 5 left the SNF area, traveled through the C Hall exit and breezeway into the Independent Living Facility, and then exited to the outside parking lot without staff knowledge or supervision. According to interviews and record review, Resident 5 joined a line of residents going to church services and then left the line, went through the C Hall exit and up the ramp into the Independent Living Facility. A dietary aide/cook reported that Resident 5 approached her in the Independent Living dining room, stated that her daughter was going to pick her up, and requested help opening the front door. The dietary aide/cook opened the front door and pushed Resident 5 through the second set of double doors into the Independent Living Facility, allowing the resident to go outside. Activity staff later observed Resident 5 wheeling herself in the back parking lot through a dining room window, went outside, and brought the resident back in, then notified the charge nurse. The DON stated that neither she nor nursing staff knew how long Resident 5 had been in the Independent Living Facility before approaching the dietary staff, and an email from the administrator indicated that Resident 5 could have been missing from 15 minutes to 1 hour. The facility also failed to ensure that exit door alarms and elopement devices were consistently used and monitored for residents at risk. The facility map showed the C Hall exit was equipped with an alarm, and the administrator stated all doors had alarms; however, the C Hall door alarm was only turned on at night and turned off during the day, while other alarms were on continuously. The entrance door was the only door connected to the branded elopement alarm system. Both Resident 5 and Resident 8 were care planned as elopement risks with branded elopement bracelets, and Resident 8 had dementia, osteoporosis, and documented wandering behavior 1–3 days on multiple MDS assessments. Their care plans included use of a branded elopement bracelet or wander alarm, but review of MARs and TARs for both residents showed no documentation of daily checks for placement and functioning of their elopement bracelets. Nursing staff interviews confirmed that daily visual checks and documentation for these devices were expected but had not been done, and the DON and ADON confirmed there was no daily documentation in place for these checks.
Failure to Assess and Document Pain Prior to Narcotic Administration
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was appropriately followed when a prescribed narcotic pain medication was administered without assessing and documenting the resident’s pain level as ordered. The resident was admitted with dementia and osteoporosis and had an order on the Medication Administration Record (MAR) for Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every six hours for moderate to severe pain, from 3/16/26 through 3/23/26. The MAR showed the medication was administered every six hours throughout the order period, yet there was no documentation of the resident’s pain level associated with those administrations. A separate MAR entry for pain assessment every shift, using a 0–10 pain scale, showed only one instance of pain greater than 0 during the relevant period, with a pain score of 3 (mild pain) on 3/19/26 at 6 AM. During interviews, the DON stated that pain levels of 0–3 indicated mild pain, 4–6 moderate pain, and 7–10 severe pain, and confirmed that the resident’s pain level should have been assessed prior to administering Hydrocodone. LN 1 confirmed that the resident’s pain level was not documented on the MAR and that there was no place on the MAR to record the pain score, but acknowledged that the pain level should have been assessed and documented before giving pain medication. The ADON similarly stated that before administering Hydrocodone, the resident’s pain level should have been assessed, that the medication was ordered for moderate to severe pain, and that there was no corresponding pain assessment. The facility’s Pain Management/Assessment Policy required pain to be assessed every shift and any time vital signs were taken, and the Medication Administration policy required that medications be administered as prescribed and that tests and vital signs upon which medication administration is conditioned be performed and recorded.
Incomplete Weekly Summary Documentation for Wound and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident, specifically in the Weekly Summary document for the week ending 3/25/26. The resident was admitted with dementia and osteoporosis. According to the Weekly Summary, the resident was documented as having no wounds, with a skin assessment entry indicating “No wounds currently” and a buttock site with MASD listed but without any treatment or effectiveness information completed. The same Weekly Summary also documented “No Pain,” with no entries in the sections for PRN pain medication use or pain type and medication used. In contrast, the resident’s Progress Notes and MAR for the same period showed that the resident had a MASD-related fissure to the upper gluteal cleft, measuring 5 x 2 cm, first documented on 3/21/26. The notes indicated the resident was incontinent of bowel and bladder, and that the physician had been notified and ordered Triad cream every shift for skin protection. Additional Progress Notes on 3/22/26 documented that staff contacted the MD to change HYDROcodone-Acetaminophen from tablet to liquid due to inadequate pain control, with the resident vocalizing mild to moderate pain when touched or moved and having difficulty taking crushed medications. On 3/23/26, the MD provided new orders for Morphine sulfate oral solution. The MAR confirmed that the resident received scheduled HYDROcodone-Acetaminophen 5/325 mg every six hours from 3/16/26 through 3/23/26 for a total of 23 doses, and then received PRN Morphine sulfate oral solution on 3/24/26 and 3/25/26 for generalized pain and discomfort. During interviews, the LN who completed the Weekly Summary acknowledged that she did not document the resident’s wound, the new orders for Triad cream, or the new pain medication orders for hydrocodone and morphine, and that she should have included these changes and the resident’s pain experiences in the Weekly Summary. The ADON and DON both confirmed that facility expectations and policies required nursing staff to document skin issues, new treatments, new medications, and weekly review of pain and pain medications on the Weekly Summary, and that the resident’s Weekly Summary did not reflect these required elements.
Failure to Monitor High-Risk Medication and Address Syncopal Episodes
Penalty
Summary
The facility failed to ensure safe monitoring practices for a high-risk medication, metoprolol, prescribed to a resident with a history of atrial fibrillation and hypertension. The medication order did not include parameters for when to hold or administer the drug based on the resident’s blood pressure (BP) or heart rate (HR). Multiple instances of abnormal BP and HR readings were documented, but there was no evidence that these results were reviewed with the resident’s physician or that the medication order was clarified to include necessary monitoring parameters. The consultant pharmacist also confirmed that recommendations for daily monitoring should have been made, but he was not notified of the resident’s syncopal episodes or abnormal vital signs during his reviews. The resident experienced multiple syncopal episodes, particularly during transfers using a standing lift, which were not consistently reported by the certified nursing assistant (CNA) to the licensed nurse (LN). When episodes were documented, there was no evidence that the resident was assessed for orthostatic hypotension or that orthostatic BP and HR checks were performed. Several LNs acknowledged during interviews that further assessment and monitoring should have occurred, and that the physician should have been notified to provide more accurate medication parameters. However, these actions were not taken, and the episodes were not communicated to the consultant pharmacist or the physician in a timely manner. The Director of Nursing (DON) was unaware of the frequency of the resident’s syncopal episodes and only became aware of one such event. Upon review, the DON acknowledged that the resident’s fluctuating BP and HR, combined with a history of syncope, warranted holding the medication, performing orthostatic checks, and notifying the physician. The facility’s policy required physician notification and inclusion of parameters for abnormal BP and HR, but these procedures were not followed, resulting in a failure to ensure safe medication administration and monitoring for the resident.
Failure to Revise Restorative Nursing Program After New Shoulder Injury
Penalty
Summary
The facility failed to revise the restorative nursing program (RNP) for a resident who was admitted with dementia, a displaced fracture of the upper end of the right humerus, and an unspecified dislocation of the right shoulder. After the resident returned from an acute hospital stay with new diagnoses of right shoulder dislocation and fracture, the RNP plan of care for passive range of motion (PROM) exercises to the upper extremities was not updated to reflect these changes. Physician orders indicated that the right arm should be immobilized and monitored, but the RNP order for PROM to the upper and lower extremities three times weekly as tolerated remained unchanged. Documentation showed that PROM exercises continued to be performed on the resident's upper and lower extremities, with no indication that PROM to the right upper arm was held, despite the presence of an immobilizer and new medical orders. Staff interviews confirmed that the RNP order was not revised, and the restorative nursing team did not review or update the plan after the resident's hospital readmission. The Director of Staff Development acknowledged that the resident should have been referred to physical therapy for screening and that the RNP should have been updated to exclude PROM to the right upper extremity. Further, there was no training provided to Certified Nursing Assistants (CNAs) or Restorative Nursing Assistants (RNAs) on the proper placement of the immobilizer or techniques for positioning and transferring the resident to avoid further injury. The Director of Rehabilitation confirmed that physical therapy did not screen the resident upon readmission, and the Director of Nursing stated that the expectation was for staff to know not to perform PROM on the immobilized arm, even though the order was not updated. Facility policy required screening for mobility status and referral to therapy for any decline, but this was not followed in this case.
Failure to Revise Elopement Risk Care Plan After Resident Found Unattended Outside
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident identified as being at risk for elopement after an incident in which the resident was found sitting outside the building unattended. The resident had a history of dementia, tremors, dizziness, and hypertension, and was unable to complete a mental status interview, indicating significant cognitive impairment. Despite being found outside the facility by staff, the care plan, which had previously identified the resident as an elopement risk, was not updated to reflect this event or to add new interventions to address the change in the resident's condition. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that the care plan was not revised following the incident, contrary to facility policy and expectations. The policy required care plans to be updated after any assessment or change in condition, and to accurately reflect current interventions and their effectiveness. The failure to update the care plan after the resident was found outside placed the resident at continued risk, as the care plan did not reflect the most current information or interventions needed to ensure safety.
Failure to Prevent Elopement Due to Unsecured Therapy Room Door
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for elopement due to diagnoses including dementia, tremor, dizziness, and hypertension, was found outside the facility by the physical therapy office back door. The resident's clinical record indicated a BIMS score of 99, signifying an inability to complete the mental status interview, and a care plan specifically identified the resident as an elopement risk with a goal to maintain safety. On the day of the incident, the resident was discovered outside by an activities team member at approximately 5:00 p.m. Interviews with facility staff revealed that the physical therapy office back door was not equipped with an alarm, and the door had been left unlocked by someone from the physical therapy department. The Assistant Director of Nursing and the Administrator both confirmed that the resident was not supposed to be in the therapy rooms unattended and that it was expected for these doors to be locked when not in use. The facility's policy emphasized the resident's right to a safe environment, but the lack of adequate supervision and failure to secure the therapy room door led to the resident's unsupervised exit.
Verbal Abuse by Licensed Nurse Toward Resident
Penalty
Summary
A deficiency occurred when a licensed nurse (LN) used verbal abuse toward a resident with a history of depression and anxiety. The resident reported to the Social Services Director that the nurse had cursed at him during a disagreement, although he could not recall the specifics of the incident. Documentation and interviews revealed that the nurse admitted to a certified nursing assistant that she had used foul language toward the resident, specifically telling him to "fuck off." This admission was corroborated by other staff members who overheard the nurse discussing the incident. The facility's event report substantiated that the nurse used inappropriate language during her interaction with the resident. The resident's records indicated intact cognitive functioning, and he later stated he felt safe and cared for in the facility, though he declined to answer further questions about the incident. The facility's policy clearly prohibits verbal abuse, including the use of swear words or demeaning remarks. The Director of Nursing acknowledged that verbal abuse could negatively affect residents' psychological and emotional well-being, emphasizing the importance of residents feeling safe in their environment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ripon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vintage Faire Nursing & Rehabilitation Center | 5.5 mi | ★★★★★ | 8 | 0 |
| Harvest Crossing Post Acute | 6.1 mi | ★★★★★ | 3 | 0 |
| English Oaks Convalescent & Rehabilitation Hospita | 6.3 mi | ★★★★★ | 13 | 0 |
| Guardian Care And Rehabilitation Center | 7.3 mi | ★★★★★ | 31 | 0 |
| Almond Vista Healthcare | 7.4 mi | ★★★★★ | 2 | 0 |
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