Health inspection·February 13, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 3 of 3 sampled Residents (Resident's 1,2 and 3) when: Residents Affected - Few 1. Resident 1 used call light to get staff attention for help, waiting over an hour. 2. Resident 2 was left soiled for a long period of time. 3. Resident 3 used call light along with roommates to help call to get assistance that took over an hour. This failure has the potential to cause (Resident's 1,2, and 3) health and safety at risk for skin break down. Findings: During interview and Records Reviewed with (Resident 1,2, and 3) indicates as followed: 1. During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: chronic pulmonary disease (lung disease that block airflow and makes difficult to breath), idiopathic peripheral autonomic neuropathy (damage to nerves causing dizziness, sweating, bladder problems), cachexia (great weight loss and muscle loss, tiredness and loss of strength). During an interview on January 21, 2025, at 3:24PM with Resident 1 (R1) R1 states, the CNAs are short staffed at night about a week ago, I had to pound to get her attention, I understand because they are with other patients. But they are short staffed. That day I was so weak; I couldn't help myself and I needed help. 2. During review of Residents 2's admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include: contracture of left and right lower leg (tightening of muscle, tendon, prevents normal movement), thyrotoxicosis (life threatening condition, overactive thyroid), blindness in one eye (unable to see). During an observation and interview on January 21, 2025, at 3:34PM, with Resident 2 (R2), R2 states, It happened 3 times, left me in soiled dirty diapers. All three times the CNA came in told me I will be back to change you; she did not come back. This happened at around 2:00AM and I got changed by morning shift around 09:00AM. They never empty my urinal (observation urinal on bedside table half full, water pitcher empty) They come in look at it and walk out instead of dumping it. I asked my CNA for a refill on water a while ago and she has yet to come back. This is all the time. Page 1 of 3 555777 555777 02/13/2025 Bishop Care Center 151 Pioneer LN Bishop, CA 93514

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. During review of Residents 3's admission Record (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: hemiplegia and hemiparesis following cerebral infarction (weakness and loss of movement to one side due to stroke, brain tissue has no blood flow), hypertension (high blood pressure), diabetes type II (body does not produce enough insulin). During an interview on January 21, 2025, at 3:42PM, with Resident 3 (R3) R3 states, It' takes about 1 hour to get assistance. It's a hit and miss but the usually it's an hour or more, I pull my cord, and I have (R2) call as well to get someone in here. I do have water here, but I must constantly ask for it, they don't just bring us water or check we have water. During an interview on January 21, 2025, at 5:10PM, with Certified Nursing Assistant CNA (CNA1) CNA1 states, there was a time, about 2 months ago, Resident 2 did complain he wasn't changed for a long time. I usually go to the nurse and give her a time frame resident told me and tell the Director of Staff Development (DSD). Some residents just complaint about not wanting this (CNA2). I think not answering call light over an hour is excessive and should not happened for resident. During an interview on January 21, 2025, at 5:13PM, with CNA3, CNA3 states, (CNA2) told me she changed Resident 2 at 3AM, but the resident was upset and told me I was waiting since 3 AM, he wanted to talk to the DSD because he was left soiled. I changed him, he had a bowel movement, it was dry by then. He was asking for water also. (CNA2) was asked, hey can you change Resident 2 before you leave and she said no she had to go pick up her daughter. During interview with the Director of Staff Development (DSD), DSD states, the only thing I heard from Resident 2 is, I think he asked CNA2 to get water, and she didn't return. At that time, we were short staffed, and she got called with another resident and she did forget to return. When I get complaints, I do a verbal with the CNA, education and disciplinary, suspension or termination depending on the issues. No resident should be left soiled, it is considered abuse. There is no excuse for lack of care, I know it wasn't malicious on the CNAs part, some days we are short staffed. During an interview with the Director of Nursing (DON), DON states, I know the CNAs get very busy and we do have issues with staffing. It's neglect the resident should not be left solid. They should not be left like this. I can agree this should not be happening. Call lights should be answered and there should be a system in place involving the nursing staff to help assist with the CNAs are with other residents. During interview with the Administrator (Admin) on January 22. 2025, Informed issues of staffing, quality of care, resident left soiled, staff not answering call lights. And residents complaining of no water being given not even when asking the staff. (Admin) states, It's up to me to admit residents, I rely on my staff also, we have said no to admitting residents due to staffing. I listen to the staff; I never want the quality of care to go down. I'm not halting any hiring; we are hiring and have registry. During a review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised [March 2018], the policy and procedure indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 555777 Page 2 of 3 555777 02/13/2025 Bishop Care Center 151 Pioneer LN Bishop, CA 93514

F 0684 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Daily Work Assignments revised [August 2006], the policy and procedure indicated, All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy, 2. CNAs and trainees are expected to carry out their daily assignments in a professional manner and in accordance with established nursing procedures . Residents Affected - Few During a review of the facility's policy and procedure titled, Answering the Call light revised [October 2010], the policy and procedure indicated, The purpose of this procedure is to respond to the resident request and needs .6. Some residents may not be able to use their call light. Be sure you check these residents frequently. 3. Listen to the resident request. 5. If you have promised the resident you will return with an item or information, do so promptly . 555777 Page 3 of 3