Cycle 1
Health 2025-03-21 · Fire 2025-03-21
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Ripon, CA
Bethany Home Society San Joaquin County
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
930 West Main Street, Ripon, CA
(209) 599-4221
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-02-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,634
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.62
Composite VBP score used to determine payment impact.
Payment multiplier
1.0024
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.37
Baseline 18.27% · Performance 19.41% · Measure score 4.37 · Achievement 4.37 · Improvement 0
Healthcare-associated infections
1.88
Baseline 5.62% · Performance 7.27% · Measure score 1.88 · Achievement 1.88 · Improvement 0
Total nurse turnover
7.74
Baseline 40.91% · Performance 32.05% · Measure score 7.74 · Achievement 7.74 · Improvement 5.02
Adjusted total nurse staffing
5.46
Baseline 5.06 hours · Performance 4.63 hours · Measure score 5.46 · Achievement 5.46 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 7.48% · Lower 95% interval 6.53% |
| Discharge to community | 63.91% |
50.57%
13.3 pts better
|
Better than the National Rate · Eligible stays 105 · Observed rate 63.81% · Lower 95% interval 54.84% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 61 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 18% |
53.69%
35.7 pts worse
|
Numerator 9 · Denominator 50 |
| Discharge mobility score | 12% |
50.94%
38.9 pts worse
|
Numerator 6 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 61 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.27% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 5.97% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 5.76% |
8.2%
2.4 pts worse
|
Numerator 8 · Denominator 139 |
| Staff flu vaccination coverage | 51.2% |
42%
9.2 pts better
|
Numerator 107 · Denominator 209 |
| Discharge function score | 26% |
56.45%
30.5 pts worse
|
Numerator 13 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 19 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 26.09% |
25.2%
0.9 pts better
|
Numerator 6 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
98.5%
0.6 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.6% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
1.6%
1.8 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 3.5% · Q4 3.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.5% |
6.8%
0.7 pts worse
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 14.3% · Q3 10.3% · Q4 0.0% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
4.1%
1.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 8.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
13.7%
1 pts worse
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 20.8% · Q3 11.4% · Q4 8.7% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
14.2%
10 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.9% · Q3 2.4% · Q4 5.1% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
10.7%
3.1 pts better
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 11.6% · Q3 2.6% · Q4 7.1% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.0%
0.5 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.1% · Q3 2.2% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.2%
0.5 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 1.8% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.1% |
10.9%
6.2 pts worse
|
19.8%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 22.3% · Q3 8.4% · Q4 24.0% · 4Q avg 17.1% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.7%
0.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.6% · Q3 5.5% · Q4 2.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
94.0%
3.5 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 98.0% · Q4 93.0% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
11.2%
6.8 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.8% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
93.2%
4.8 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.3% |
23.2%
10.1 pts worse
|
23.9%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.3% · Observed 31.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-04 · Fire 2022-11-04
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-05-09 · Fire 2019-05-09
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-08
F · Potential for more than minimal harm
2025-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-08
C · Minimal harm
2025-03-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-08
F · Potential for more than minimal harm
2022-11-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-22
E · Potential for more than minimal harm
2022-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-22
D · Potential for more than minimal harm
2019-05-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-16
D · Potential for more than minimal harm
2019-05-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-09-08
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-07-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-10
E · Potential for more than minimal harm
2025-03-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-21
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-04-07
D · Potential for more than minimal harm
2023-10-24
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-24
D · Potential for more than minimal harm
2023-10-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-12
D · Potential for more than minimal harm
2023-10-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-10-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-04
D · Potential for more than minimal harm
2023-09-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-22
E · Potential for more than minimal harm
2022-11-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-04
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-03
F · Potential for more than minimal harm
2019-05-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-06-05
F · Potential for more than minimal harm
2019-05-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-05
E · Potential for more than minimal harm
2019-05-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-06-05
E · Potential for more than minimal harm
2019-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-05-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-05
Penalties and ownership
What sits behind the stars
Ownership
Beck, Tom
Corporate Director · Individual
Duyst, Pete
Corporate Director · Individual
Fredriks, Joni
Corporate Director · Individual
Meester, Henry
Corporate Director · Individual
Miller, Jeff
Corporate Director · Individual
Mulder, Melvin
Corporate Director · Individual
Scheublein, Cindy
Corporate Officer · Individual
Scheublein, Cindy
W-2 Managing Employee · Individual
Slager, Carol
Corporate Director · Individual
Vanelderen, Dave
Corporate Director · Individual
Vangroningen, Debra
Corporate Director · Individual
Vanhouten, Adrian
Corporate Director · Individual
Vermeulen, Tom
Corporate Director · Individual
Vieyra, Hilario
Operational/Managerial Control · Individual
Vieyra, Hilario
W-2 Managing Employee · Individual
Weaver, Elva
Corporate Director · Individual
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