Other·May 2, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to investigate a complaint. Complaint Number CA00525797 Representing the California Department of Public Health: 33786 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as a result of complaint number CA00525797

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 05/21/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555777 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BISHOP CARE CENTER 151 Pioneer Ln Bishop, CA 93514 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent a fall for one of three sampled residents (Resident A) when a certified nursing assistant (CNA 1) left Resident A unattended in the bathroom. This failure resulted in Resident A to experience a fall on March 18, 2017 and sustain a laceration (deep wound) of the forehead requiring sutures (stitches). Finding: An unannounced visit was made to the facility on March 22, 2017 at 4:45 PM, to investigate a complaint regarding quality of care. During an observation on March 23, 2017 at 9:35 AM, in Resident's room, Resident A was lying in bed with bandages on top of his head. During an interview with Resident A, on March 23, 2017 at 9:45 AM, he stated, "I fell...I couldn't reach the call light. I got dizzy. The toilet bowel was spinning and I fell down on the floor of the bathroom. There was a lot of blood. The door was shut. My roommate shouted and shouted and finally someone came." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555777 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BISHOP CARE CENTER 151 Pioneer Ln Bishop, CA 93514 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation on March 23, 2017 at 10 AM, in Resident A's bathroom in room 109, the call light string was observed to be tied in knots, shortening the length of the cord. A review of Resident A's clinical records, reflected Resident A was admitted to the facility on May 28, 2015, with diagnoses which included: chronic obstructive pulmonary disease (disease of the lungs), hypertension (high blood pressure), and heart failure (disease of the heart). A review of the physician's history and physical, completed on May 27, 2014, indicated Resident A does have the capacity to understand and make his own decisions. A review of the Fall Risk Assessment dated March 9, 2017, indicated Resident A's fall risk score was 15, and Resident A was considered at risk for falls. A review of the Resident Assessment Instrument (RAI-a computerized assessment tool) section G, dated March 7, 2017, indicated Resident A required extensive assistance in toileting. During a review of the clinical record for Resident A, the licensed nurse's progress notes dated March 18, 2017 at 8:17 PM, indicated, "Resident found on floor of bathroom. Staff was alerted to resident fall by his calling out. Resident stated that he was attempting to reach call string and then became dizzy. Was sent out to hospital at 7:35 PM." During an interview with the certified nursing assistant (CNA 1), on April 14, 2017 at 4:35 PM, she stated, "I got him out of bed, and took him to the bathroom. I transferred him to the toilet. I left the room to provide privacy. I went FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555777 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BISHOP CARE CENTER 151 Pioneer Ln Bishop, CA 93514 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE next door. The next thing I knew, he had fallen." She confirmed she left Resident A unattended in the bathroom and stated, "Now I know that I should have not left him alone." During an interview with a Licensed Vocational Nurse (LVN 1), on April 19, 2017 at 3:55 PM, he stated he was the charge nurse on duty when Resident A fell on March 18, 2017. He stated Resident A was left alone in the bathroom. Resident A was found by CNA 2 who happened to go to the room and find Resident A on the ground. CNA 2 was not available for interview. A review of Resident A's care plan dated November 25, 2016, indicated the resident was on a scheduled toileting plan related to a history of falls from attempting to use the bathroom unassisted. The intervention listed included provide physical staff assistance for toileting. During a review of the policy and procedure titled," Assisting a Resident to walk to the bathroom" dated October 2010, indicated under the section titled "Steps in Procedures...13. Tell the resident to call or signal for you. Wait outside the door, if permitted. 14. When the resident has signaled or called you, return to the bathroom." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555777 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BISHOP CARE CENTER 151 Pioneer Ln Bishop, CA 93514 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F463 RESIDENT CALL SYSTEM ROOMS/TOILET/BATH CFR(s): 483.90(g)(2)

F463 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/21/2017 (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area (2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an emergency call light in the bathroom was able to be reached for one of three sampled residents (Resident A). This failure resulted in Resident A to experience a fall on March 18, 2017 and sustain a laceration (deep wound) of the forehead requiring sutures (stitches). Finding: An unannounced visit was made to the facility on March 22, 2017 at 4:45 PM, to investigate a complaint regarding quality of care. During an observation on March 23, 2017 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555777 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BISHOP CARE CENTER 151 Pioneer Ln Bishop, CA 93514 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9:35 AM, in resident's room, Resident A was lying in bed with bandages on top of his head. During an interview with Resident A, on March 23, 2017 at 9:45 AM, he stated, "I fell...I couldn't reach the call light. I got dizzy. The toilet bowel was spinning and I fell down on the floor of the bathroom. There was a lot of blood. The door was shut. My roommate shouted and shouted and finally someone came." During an observation on March 23, 2017 at 10 AM, in Resident A's bathroom in room 109, the call light string was observed to be tied in knots, shortening the length of the cord. During an interview with a Licensed Vocational Nurse (LVN 3), on March 23, 2017 at 10:15 AM, she stated, "The call light string is short. I don't know how long that has been like that. I would make it a little longer. He [Resident A] would have to reach for it which would throw him of balance." She confirmed the call light string was tied in knots shortening the length of the cord and stated, "It should not be like that." During an interview with the Director of Nurses (DON) on March 23, 2017 at 10:45 AM, she confirmed the call light string was tied in a knot. The emergency call light string was measured. It measured 2 feet when tied in a knot and 2 feet 11 inches when untied. She stated, "It should not be like that. Let me unknot it and make it longer." During a review of the clinical record for Resident A, the licensed nurse's progress notes dated March 18, 2017 at 8:17 PM, indicated, "Resident found on floor of bathroom. Staff was alerted to resident fall by his calling out. Resident stated that he was attempting to reach call string and then became dizzy. Was sent out to hospital at 7:35 PM." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555777 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BISHOP CARE CENTER 151 Pioneer Ln Bishop, CA 93514 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Fall Risk Assessment dated March 9, 2017, indicated Resident A's fall risk score was 15, and Resident A was considered at risk for falls. A review of Resident's A's "Fall" care plan dated May 29, 2015 indicated the resident was at risk for falls. The intervention listed included call light within reach. During a review of the policy and procedure titled, "Answering call light" dated October 2010, indicated under "Policy, the purpose of this procedure is to respond to the resident's requests and needs." In the same policy under "General Guidelines... 2. Demonstrate the use of the call light. 3. Ask the resident to return the demonstration...explain to the resident that a call system is also located in his/her bathroom. Demonstrate how it works." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UQP511 Facility ID: CA240001854 If continuation sheet 7 of 7