Other·October 22, 2018

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: CA00595746 Representing the California Depatment of Public Health: 37837 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Census: 70

F622 SS=F Transfer and Discharge Requirements CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii)

F622 10/05/2018 §483.15(c) Transfer and discharge§483.15(c)(1) Facility requirements(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable 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: SQ1G11 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 09/26/2018 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 and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c) (1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SQ1G11 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 09/26/2018 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 (c)(2)(i) of this section must be made by(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to notify the ombudsman of facility initiated transfers and discharges during the months of January 1, 2018 through July 17, 2018, for 29 of 57 Residents (Resident 1 through 29) who were discharged or transferred from the facility. The 29 facility generated transfers and discharges were not reported to the Ombudsman. This failure had the potential to result in 29 Residents (Resident 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 and 29) not receiving the added protection the Ombudsman provides by ensuring these residents did not leave the facility without access to an advocate who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SQ1G11 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 09/26/2018 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 could confirm their patients' rights for a safe discharge and that they were not inappropriately discharged. Findings: An abbreviated survey was initiated on July 17, 2018, to investigate a complaint regarding the Ombudsman not being notified of facility initiated transfers to the general acute care hospital or discharges as per regulatory requirement. During an interview with the Director of Nursing on July 17, 2018 at 2:20 PM, she stated "I'm not familiar with most of California regulations yet. In my understanding no need to inform the ombudsman about residents who will be discharged." During a phone interview with the Ombudsman on August 8, 2018 at 10:05 AM, she stated, "They have not given me one discharge report. I gave the All Facility Letter (AFL-letters sent to affected facility types from the California Department of Public Health when regulations are changed, which requires the facility to notify the ombudsman of discharges) to the Administrator and the social services designee." During a concurrent interview and record review with the Social Services Designee (SS1) on August 8 2018, at 11:39 AM the clinical records for Residents 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, and 29, she confirmed there was no documentation that stated the discharges were requested by the resident or their responsible party. SS1 confirmed the Ombudsman was not notified of the transfers or discharges initiated here at the facility. SSI further stated, "Here (at this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SQ1G11 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 09/26/2018 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 facility), we've never done that, notified the Ombudsman (when a resident is discharged)." 1. Resident 1 was discharged to home on January 2, 2018. 2. Resident 2 was transferred to the General Acute Care Hospital (GACH) on January 5, 2018. 3. Resident 3 was transferred to the GACH on January 6, 2018. 4. Resident 4 was transferred to the GACH on January 7, 2018. 5. Resident 5 was discharged to home on January 17, 2018. 6. Resident 6 was discharged to home on January 30, 2018. 7. Resident 7 was transferred to the GACH on February 13, 2018. 8. Resident 8 was transferred to the GACH on February 20, 2018. 9. Resident 9 was discharged to home on February 21, 2018. 10. Resident 10 was transferred to the GACH on February 24, 2018. 11. Resident 11 was discharged to home on March 7, 2018. 12. Resident 12 was discharged to home on March 10, 2018 13. Resident 13 was transferred to the GACH on March 28, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SQ1G11 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 09/26/2018 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 14. Resident 14 was transferred to the GACH on April 2, 2018. 15. Resident 15 was discharged to home April 9, 2018. 16. Resident 16 was discharged to home April 18, 2018. 17. Resident 17 was discharged to home April 21, 2018. 18. Resident 18 was discharged to home April 24, 2018. 19. Resident 19 was discharged to home April 27, 2018. 20. Resident 20 was discharged to another long term care facility on May 14, 2018. 21. Resident 21 was discharged to home May 14, 2018. 22. Resident 22 Resident 8 was transferred to the GACH on May 28, 2018. 23. Resident 23 was discharged to home June 2, 2018. 24. Resident 24 was discharged to home June 8, 2018. 25. Resident 25 was discharged to home June 8, 2018. 26. Resident 26 was discharged to home June 16, 2018. 27. Resident 27 was discharged to home June 28, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SQ1G11 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 09/26/2018 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 28. Resident 28 was discharged to home July 3, 2018. 29. Resident 29 was discharged to home July 7, 2018. During an interview with the Administrator on August 8, 2018 at 2:13 PM, he stated, "We heard different stories with the Ombudsman. We had a phone call two weeks ago. We were getting conflicting messages. We thought, Facility initiated meant giving a 30-day notice." The administrator confirmed that the facility had not sent any discharge notices to the Ombudsman. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SQ1G11 Facility ID: CA240001854 If continuation sheet 7 of 7