Health inspection·February 14, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure three of five residents (Residents 1,2, and 3) received or were offered fluids during the day and night. Residents Affected - Few This failure had the potential in putting Residents 1, 2 and 3's health and safety at risk when not receiving fluids to meet daily requirements consistent with resident's comprehensive assessment. Findings: 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: 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 a concurrent observation and interview on January 21, 2025, with Resident 1 (R1), R1 stated, 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. 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. 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: 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 3:34PM with Resident 2 (R2) R2 stated, 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 (R1) 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. 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: congested heart failure (heart doesn't pump blood as well), hypertension (high blood pressure), muscle weakness, lesion of sacral spinal cord (damage to the nerves can cause loss of bladder, pain and difficulty walking.) During an interview on January 21, 2025, with Resident 3 (R3), R3 states, they do take 30 minutes to an hour to get assistance. I must call to get water; then don't refill it, you need to call every Page 1 of 3 555777 555777 02/14/2025 Bishop Care Center 151 Pioneer LN Bishop, CA 93514

F 0692 time to get more water. Level of Harm - Minimal harm or potential for actual harm During an interview on January 21, 2025, at 5:10PM with a Certified Nursing Assistant (CNA1), CNA1 stated, The water pitcher the white color is for day shift, someone passes them out 8:00AM, snacks and another water pass are around 11:00 AM then another snacks. Night shift CNAs we pass out water and offer it to residents. I will ask my residents if they need water. Residents Affected - Few During an interview on January 21, 2025, at 5:13PM, with CNA2, CNA2 stated, We pass out water twice on our shift, [a staff assigned] at 9:30AM and 2:30PM, if the residents' water runs out, the resident asks for water. During an interview on January 22, 2025, at 9:02AM with the Kitchen Supervisor (KS), KS stated, the ice machine storage room is where the clean trays of clean water pitchers are for residents. We are constantly washing the water pitchers. The water pitcher color for morning is white and night is red color pitcher, there are some red pitchers in Ice machine room, I have more in storage. During an interview on January 22, 2025, at 9:12AM, with CNA3, CNA3 stated, I am starting off late today, but usually I start 6:30AM, all water pitchers are passed before 8:00AM, then I go on to pass trays and feed residents. At 9:30AM I start snacks. The white colored pitchers are in morning and the red colored are in the afternoon. When I'm not here I don't know who passes out the water, it should be the CNAs. I'm running late today, and someone should be passing water around 3:00PM. During on Observation on January 22, 2025, at 9:30AM, room [ROOM NUMBER] A and B bed did not have red colored pitcher from night shift, white pitchers were noted with no water in them for the residents in A and B bed. Surrounding rooms were observed to have white water pitchers, not maroon colored water pitchers as is should be, since no water has been passed out yet. Interview with CNA3, stated, the water pitchers should be red colored because I have yet to pass out water this morning, they should not have been white pitchers. During record review on January 21, 2025, at 11:07AM, A review of the Resident Council minutes indicated the following: 1. December 19, 2024: Residents discussed concerns about: Staffing, not getting water hydration and snacks at night and call lights not being answered. 2. November 21, 2024: Residents discussed concerns about: Staffing (not enough), staff ignoring call lights, looking at their phones, they don't get help. During an interview, with the Director of Nursing (DON), what date and time? The DON stated, Regarding the hydration, Hospitality (CNA 3) does this, the hydration is done by her in the morning shifts, the rest of passing water pitchers and offerings are done by the CNAs and license. It's the CNAs' responsibility to be handing out fresh water. Informed DON of observations. The DON stated, It should had been a red or burgundy color [water pitcher] because if CNA3 did not yet pass out the waters in the morning, the water pitcher should still have been burgundy color from PM shift. [NAME] pitcher is for morning shift. I know they get very busy, and we do have issues with staffing. I can agree the staff should be hydrating residents on all shifts. 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 555777 Page 2 of 3 555777 02/14/2025 Bishop Care Center 151 Pioneer LN Bishop, CA 93514

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. During a review of the facility's policy and procedure titled, Resident Hydration and Prevention of Dehydration revised [October 2017], the policy and procedure indicated, This facility will strive to provide adequate hydration and to prevent and treat dehydration. 555777 Page 3 of 3