Bethany Home Senior Living, Llc.

On 04/22/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Administrator, Rachell Paniagua, and explained the purpose of the visit. The facility currently houses 28 residents with a max capacity of 58 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 107.8 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/27/2025. At 11:30AM, LPA reviewed five (5) resident files and six (6) staff files, all found to be complete. The emergency disaster plan was last reviewed 06/26/2025. Quarterly emergency drills were last conducted 01/27/2026 with an upcoming drill 04/24/2026. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.

On 03/25/26, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint. During the health and safety check, LPA observed a total of 6 staff members and 10 residents at the facility through out the shared spaces. LPA toured facility with Executive Director, including but not limited to bedrooms, kitchen, dining rooms, activities rooms. LPA observed residents comfortable in their surroundings. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

On 5/15/2025 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Manager, Rachell Paniagua and explained the purpose of the visit. During visit, LPA reviewed infection control plan, LIC500, and fire drill logs. Last fire drill was conducted on 4/29/2025. LPA interviewed 3 residents and 3 staff during inspection. No deficiencies are being cited on this date. Exit interview conducted with Rachell Paniagua. A copy of this report provided.

On 4/23/2025 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Manager, Rachell Paniagua and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 5/17/2024. Evacuation chairs were observed in both stairwell on the third floor. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food once a week. Freezer’s temperature was registered at 0 degree F while the refrigerator’s temperature was recorded at 37 degrees F. Hot water temperature was measured at 112.6 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats were observed. LPA reviewed 5 resident records and 5 staff records starting at 11:42AM. LPA reviewed a sample of resident's medications during inspection. LPA will return at a later time to complete annual inspection. No deficiencies are being cited on this date. Exit interview conducted with Rachell Paniagua. A copy of this report provided.

Interview with W1 indicated that R1’s pressure injuries developed prior to admission to the facility. W1 believed that R1’s prior placement was responsible for R1’s pressure injuries. Incident report dated 3/23/2022 revealed that the facility reported R1 had two pressure injuries during admission. Interview with staff and residents indicates consistent statements of staff being attentive to the resident’s care needs. Staff knew to assist R1 with rotating and check on R1 frequently. R1 stated that he was receiving hospice care for coccyx pressure injury. Staff failed to provide mobility equipment required to move bedridden resident in care R1’s physician’s report dated 3/2/2022 indicated that R1 is non-ambulatory. R1’s functional capability assessment dated 3/7/2022 revealed that R1 requires assistance with transferring, but able to reposition from side to side. R1’s medical and hospice records did not indicate that R1 required mobility equipment for transfers. Interview with witness revealed that facility staff was assisting R1 in repositioning. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted with Chearamy Evangelista. A copy of this report provided.

Page 2 The Department interviewed the following: staff members on 5/31/23, 6/19/23 and 7/11/23; home health staff (HH1 and HH2) on 4/19/23, 5/04/23 and 6/20/23; residents (R2 and R3) on 5/31/23. Allegation: Resident (R1) developed pressure injuries while in care. On 10/10/22, R1 fell from the bed, was transferred to hospital, and diagnosed with hip fracture. R1 had hip surgery and was discharged back to the facility. R1 was followed by home health for her wound care and to remove staples from surgery. R1 developed pressure injuries while with home health care. Home Health (HH1 and HH2) provided instructions to caregivers on how to care for the pressure injuries and instructed the caregivers to elevate R1’s legs and heels so the pressure injury could heal. HH1 stated that R1 was known to refuse to be turned, refuse to have the dressings changed, and that R1 was combative towards HH1. Interviews with staff (S3 and S4) confirmed that they were rotating R1 as directed by R1’s doctor’s and home health orders. Staff were also changing R1’s bandages in-between home health visits, when R1’s bandages became soiled or were coming off. Staff were using booties and pillows to float R1’s heels off the bed to further prevent the pressure injuries from getting bigger. An interview with facility manager, S1, revealed that staff were cleaning R1’s injures with saline solution as directed by home health to keep the wounds clean. The facility also provided R1 with booties for her heels when the equipment was not available from the home health agency. Based on all information obtained, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. ....continued on 9099C (page 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 Allegation: Facility did not follow resident's care plan On 07/11/2023, a follow up interview with facility manager, S1, and caregiver, S4, revealed that the facility followed the instructions provided by the home health nurses regarding the use of pillows and booties to float R1’s feet off the bed. R1 would kick the pillows off the bed and kick the booties off. Staff would check to make sure that pillows and booties were put back on R1’s feet to prevent the pressure injuries from becoming worse. As directed by home health, the facility staff would also change R1’s bandages and clean R1’s pressure injuries with saline solution in between home health visits. Based on all information obtained, the allegation is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Allegation: Resident sustained fracture resulting from fall. On 10/10/2022, caregiver S2 was in R2’s room and witnessed R1 fall from her bed to the floor. R1 was in extreme pain and could not stand. Other caregivers came to the room and helped S2 lift R1off of the floor and onto the bed. 9-1-1 was called and R1 taken to the hospital. It was confirmed that R1’s hip was fractured from the fall. R1 did not have any injuries or hip problems before R1 fell off the bed. R1 was not a fall risk, did not have any prior falls, was able to walk on her own with the assistance of a walker, and was not required to have two or more staff help with transfers in and out of the bed. Two residents (R2 and R3) were interviewed on 5/31/23 who both stated they were never hurt by staff. Both stated staff check them but were not able to provide the timetable on how often they are checked. Based on all information obtained, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

On 10/4/2023 at 10:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Manager, Rachell Paniagua and informed her the reason for visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 108.9 degrees F in a hallway bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility purchase food once a week. Freezer temperature was measured at 0 degrees F and refrigerator temperature was measured at 39 degrees F. Resident's medications were kept locked in the medication cart located in the medication room. Medication room is locked and require security code to enter. Smoke and Carbon monoxide detectors observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/10/2023. There are no accessible bodies of water observed. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report was provided.

On 8/3/2023 at 6:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 7/24/2023. LPA met with Manager, Rachell Paniagua. LPA received incident report on 7/24/2023 for resident (R1). Incident report revealed that R1 was caught climbing out the bedroom window and caregivers tried to stop R1. However, R1 was aggressive and layed down on the roof. Caregiver held R1's feet until police and fire department arrived. LPA interviewed staff. LPA was informed that R1 climbed out of the window on the third floor and was on the roof. R1 laid down with a pillow on the ledge of the roof right outside the bedroom window. Staff called 911 and police/fire department arrived less than 5 minutes. LPA observed window had alarms and would signal when windows are open. Windows have window screen. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Unqualified staff providing care to residents Staff did not receive on the job training LPA reviewed a sample of staff training for year 2022 and observed that staff have initial and/or annual training including dementia, medication administration, and caregiver shadowing. Staff did not prevent resident from engaging in dangerous activities Interview with staff indicated there was no residents that left the facility and climb on the roof in summer of 2022. Staff stated that R5 attempted to climb out of the bedroom window from the second floor last year, but staff was able to intervene and prevented R5 from climbing out of the window. Facility windows have window screens. Staff did not prevent residents from wandering from the facility Interview with residents and staff indicated that no resident wandered outside of the facility and was found on the street in summer of 2022. Staff stated that a resident wandered outside the building, but staff followed the resident and redirected them back inside the facility. Staff did not check on residents in a timely manner Interview with staff revealed that residents are checked every 2 hours for incontinence care. Staff stated that residents have pendents and response time is 5-10 minutes. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided.