555777
03/12/2025
Bishop Care Center
151 Pioneer LN Bishop, CA 93514
F 0727
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Based on interview, record review, and facility document and policy review, the facility failed to ensure there was registered nurse (RN) coverage eight consecutive hours, seven days a week for 6 days (10/23/2024, 11/17/2024, 11/24/2024, 12/01/2024, 12/08/2024, and 12/22/2024) during Fiscal Year (FY) 2025, Quarter 1 (October 2024, November 2024, and December 2024) and 3 days (02/23/2025, 03/01/2024, and 03/02/2025) during the timeframe from 02/11/2025 through 03/11/2025.
Findings included: A facility policy titled, Staffing, Sufficient and Competent Nursing, revised 08/2022, specified, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The policy indicated, 3. A registered nurse [RN] provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A PBJ [Payroll-based Journal] Staffing Data Report CASPER [Certification and Survey Provider Enhanced Reports] Report 1705D FY Quarter 1 2025 (October 1 - December 31), with a run date of 03/05/2025, revealed the facility triggered for No RN Hours on the following Sundays: 10/13/2024, 11/17/2024, 11/24/2024, 12/01/2024, 12/08/2024, and 12/22/2024. Cross-reference of a facility schedule dated 10/13/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility on 10/13/2024. Cross-reference of a facility schedule dated 11/17/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 11/17/2024, revealed the Director of Nursing (DON) was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 11/24/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 11/24/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM.
Page 1 of 2
555777
555777
03/12/2025
Bishop Care Center
151 Pioneer LN Bishop, CA 93514
F 0727
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Cross-reference of a facility schedule dated 12/01/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 12/01/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 12/08/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 12/08/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. Cross-reference of a facility schedule dated 12/22/2024 with a facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled to work in the facility. A Nursing Staffing Assignment and Sign-In Sheet, dated 12/22/2024, revealed the DON was scheduled on call from 8:00 AM to 4:00 PM. A facility schedule for the timeframe from 02/11/2025 through 3/11/2025, highlighted in green by the facility to indicate which nurses were RNs, revealed there was no RN scheduled for 02/23/2025 and 03/02/2025. Additionally, the schedule revealed there was an RN scheduled for only four hours on 03/01/2025. During an interview on 03/12/2025 at 9:20 AM, RN #3 stated there had been times when there was no RN scheduled to work in the facility. RN #3 stated that RNs were needed in the facility to administer treatments that licensed vocational nurses (LVNs) were not trained to do. During an interview on 03/12/2025 at 9:31 AM, the DON stated that an RN needed to be in the building seven days a week for eight consecutive hours each day. She stated she was on-call for some of the weekends that had no RN coverage in the facility. She clarified that being on-call was different from being in the facility, adding that on-call did not mean she was physically present in the facility. The DON stated the facility was not meeting the regulatory requirement and said the facility's schedule needed to be rearranged. During an interview on 03/12/2025 at 9:57 AM, Acting Administrator #1 and Acting Administrator #2 confirmed there needed to be an RN in the building eight consecutive hours a day, seven days a week. They both stated not having RN coverage in the building could be avoided with some reorganization of the schedule.
555777
Page 2 of 2
