Mayers Memorial Hospital

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure appropriate discharge (the safe release of a patient from a hospital, or medical facility when they are medically stable, able to manage self-care, or have arranged support) for one of two residents sampled (Resident 1) when:1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 7 sampled residents (Residents 17 and 19) were treated with dignity and respect when the facility did not have portable oxygen tanks (can be taken anywhere) available and the residents had no choice but to use oxygen concentrators (a large, noisy, and not portable machine that requires electricity). This failure resulted in preventing Resident 2 and 7 from going anywhere there was not an electrical outlet, such outdoors, to appointments and out on pass with their family. This caused Resident 2 and 7 to feel embarrassed, confined, angry and anxious, which resulted in mental aguish and loss of dignity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment when 6 out of 8 resident bathrooms observed were found to have unsanitary conditions around the toilets and floors. This was unsightly with the potential to cause health issues due to bacteria and cause the residents psychological stress and depression. During a review of the facility’s, “Resident [NAME] of Rights”, undated, the [NAME] of Rights indicated, (e ) The facility shall be clean, sanitary, and in good repair at all times.” During an observation and interview on 8/5/25 at 3:30 pm, while in resident room [ROOM NUMBER] with Family Member (FM) H. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to meet this requirement when three of five sampled residents (Residents 3, 5, and 29) with dementia (a brain problem that affects memory and behavior), received antipsychotic medications (drugs that regulate or control thinking and behaviors) without an adequate indication for use (target symptom or behavior) when: 1. Specific, measurable, behaviors that are not subjective;2. Non-pharmacologic (non- drug) interventions were tried to address residents' behaviors prior to administering antipsychotic agents, and;3. A physician's response to the pharmacist's recommendations for use of these medications was not done. These failures had the potential for unwanted and adverse medication side effects including; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 69 when the controlled drug (medication that may be abused or cause addiction) record form was not filled out and signed accurately. This failure could result in diversion of the residents' unused controlled medications. During an inspection of the controlled medication bin located in the medication room on 8/4/25 at 1:22 p.m., the controlled medication bin was observed to be locked and sealed with a numbered zip tie, 9973377, which was different than the recorded tag number, 9973375, on the controlled count sheet. During an interview on 8/4/25 at 1:25 p.m. with Charged Nurse (CN) A, CN A confirmed that the number stated on the numbered zip tie was not the same as the number recorded and signed by her on the controlled count sheet. [...]

Inspectors wroteThis regulation was not met when pharmacy recommendations were not followed or responded to by the Physician, Director of Nursing or nursing staff for three of six sampled residents (Residents 3 ,5, and 29), for periods of up to six months (120 days). This had the potential for residents to remain on unnecessary medication and potentially exposing them to unnecessary unwanted and adverse side effects of those medications, which included falls, confusion and death by heart related problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 2 of 6 sampled residents (Resident 40 and 4).1. For Resident 40, a licensed nurse was unable to administer Resident's 40's doxycycline, a medication to treat and prevent infections, with the rest of resident's morning medications when doxycycline was not available to be administered per Physician Orders.2. For Resident 4, a licensed nurse did not administer Resident 4's omeprazole, a medication to treat certain conditions where there is too much acid in the stomach, as ordered by the physician. As a result, 2 errors were identified out of 31 opportunities for error during the observation of medication administration; the facility medication error was 6.45%.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when:1. An expired 3 ml (milliliter, unit of measure) insulin lispro pen, medication used to treat high blood sugar levels, was found in the medication cart. 2. An expired 5 ml multidose vials of Tuberculin purified protein derivative testing agent, a solution used in a skin test to diagnose latent lung infection, was found in the medication room B's refrigerator. These failures had the potential for medication error, misuse, or administering expired and ineffective medications to the residents.1. During an inspection of medication cart Hall #2 with Licensed Nurse (LN) A on 8/4/25 at 1:19 p.m., an expired insulin lispro pen was found with an expiration date of 7/22/25 on the label. During an interview on 8/4/25 at 1:20 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when a blood pressure monitor (device used to measure blood pressure) was not disinfected according to manufacturer's instructions after being used during medication pass observation. This failure had the potential to transmit blood-borne pathogens or bodily fluids between residents. During a medication pass observation with Licensed Nurse (LN) A on 8/5/25 at 8:30 a.m., LN A used a blood pressure monitor to measure Resident 40's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident room's and placed on the medication cart without being cleaned and disinfected. [...]

Inspectors wroteBased on interview, record review, facility policy review and video surveillance review, the facility failed to ensure that the pharmacist was responsible for establishing a system of records of receipt and disposition of all controlled medications (medications that have a high potential for abuse and addiction) in sufficient detail to enable an accurate reconciliation, and to ensure that these drugs were handled and administered in a safe and secure manner. This failure allowed narcotic medications to be diverted (stolen or misused) without detection, compromising the facility's ability to ensure the safe and effective use of medications. Residents were placed at potential risk of unrelieved pain, undertreatment, and harm from diverted medications.

Inspectors wroteBased on interview and record review, the facility failed to implement care planned fall prevention interventions (a set of proactive measures designed to minimize the risk of falls in individuals) for 2 of 4 residents sampled for falls who had been identified as high risk for falls (Resident 1 and 2) when: 1. Resident 1's care planned intervention for staff to follow Resident 1 to his room and assist him with toileting or lying down was not followed. 2. Resident 2's care planned intervention to ensure that Resident 2 was wearing non-skid socks or footwear was not followed. These failures resulted in avoidable falls with broken hips for both Resident 1 and 2 which and rehospitalizations for surgical repairs. This had the potential to negatively impact the residents' physical and emotional well-being and subject them to further falls with injuries.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical and verbal abuse for two of six sampled residents (Resident 3 and Resident 4) when Certified Nursing Assistant (CNA) A was rough with Resident 3 and CNA H cursed and threw personal care items toward Resident 4. These failures violated Resident's 3 and 4's right to be free from abuse and caused Resident 4 to fear CNA H. These failures and had the potential to subject residents to physical harm, mistreatment and negatively impact their emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation of an allegation of staff to resident abuse was conducted for one of six sampled residents (Resident 3). This failure had the potential to put all residents of the facility at risk for staff to resident abuse.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure Resident 4 was monitored specifically for any problems resulting from the abuse he experienced when Certified Nursing Assistant (CNA) H was rough with Resident 4 and threw personal care items at him on 1/10/25, when they did not complete change in condition charting (documentation done just after an unexpected incident occurs that had a negative effect on a resident to communicate the resident's condition to other healthcare providers), and alert charting (ongoing documentation of monitoring for 72 hours after an accident, injury, or incident to reassess if any problems occurred over time resulting from the accident, injury, incident), was initiated late. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure their abuse reporting policy was followed for six of 14 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) sampled for abuse when: 1. Resident 1 had an altercation with Resident 6 and the follow-up investigation was not sent to California Department of Health (CDPH) as per facility policy. 2. Resident 4 was accused of an altercation with Resident 3 and Resident 5 and the follow-up investigation was not sent to the CDPH as per facility policy. 3. Resident 2's family member (FM) was accused of verbally abusing Resident 2 and the facility did not report the alleged abuse to the CDPH withing 24 hours per facility policy. This failure had the potential to subject residents to mistreatment, neglect or abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent verbal abuse for one of three sampled residents (Resident 1) when Registered Nurse (RN) A yelled and cursed at Resident 1 and told Resident 1 to not use her call light. This mistreatment caused Resident 1 distress and feelings that her needs were not met and had the potential to affect all residents under the care of RN A and negatively impact their quality of life and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of seven sampled residents (Resident 1, 2, 3, 4 and 5) were free from verbal abuse when Certified Nurse Assistant (CNA) 1 verbally abused Residents 1, 2, 3, 4, and 5. This failure had the potential to negatively impact Resident 1, 2, 3, 4, and 5's sense of security, increased loss of dignity, and humiliation and emotional, and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two residents (Resident 1 and Resident 2), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 and Resident 2 eloped from the facility and had no wander/elopement risk assessments at the time of their elopements. These failures resulted in Resident 1 eloping from the facility from an unknown exit at an unknown time and being found in the facility ' s parking lot by a staff member who happened to go out to the parking lot. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required daily Registered Nursing (RN) hours for Payroll Based Journaling (PBJ) staffing information submitted to the Centers for Medicare and Medicaid Services (CMS). Failing to meet the required hours the facility did not ensure an adequate level of staff is working at a given time, potentially leading to inadequate care of residents and adverse clinical outcomes. FINDINGS During a concurrent record review and interview on 05/09/24 at 12:33 PM, the Quality Manager (QM) confirmed the required RN coverage was not met for 20 days of the first Federal Quarter of 2024 (The first Federal Fiscal Quarter begins October 1st of the prior year, in this case, October 1st, 2023). The QM stated, It is all here and matches the PBJ report on these dates. We did not have an RN present on the schedule. [...]

Inspectors wroteBased on interview and record review, the facility failed report abuse allegations on 4/8/24 and unknown date for Resident 10 and reported late for Resident 50 and 278 when: 1. One of three sampled residents (Resident 10) was verbally and physically abused. 2. Two of three sampled residents (Resident 50 and 278) were reported late.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the Care Plans for two of four sampled residents (Residents 27 and 128) when information about their risk for elopement (leaving the facility without staff's knowledge) and exit alarm devices was not included in their Care Plans. This failure had the potential to put the residents at risk for accidents related to elopement. Refer to F 689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure the environment was free of all accident hazards for two of four sampled residents (Residents 27 and 128) when they had orders for Wanderguard ® (a device worn on the body that caused an alarm to sound at exit doors) placement, with no follow-up or monitoring. This failure had the potential to put the residents at risk for accidents related to elopement (leaving the facility without staff's knowledge). Refer to F 657.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents sampled for abuse (Resident 10) was free from physical and verbal abuse, when confidential informant (CI1) witnessed the Director of Nursing (DON) yelling at and shaking Resident 10's wheelchair. This failure resulted in physical and verbal abuse to Resident 10 and had the potential for a decline in Resident 10's psychosocial wellbeing and isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. the interior of the microwave oven was not clean; 2. two expired food items were available for use; 3. one food item was not labeled with a use-by date; 4. one canned item had a dent on its seam. These failures had the potential to result in foodborne illness for a facility with a census of 79 residents who consumed food prepared in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had the knowledge and resources (cleaning supplies or cleaning materials), required to provide a safe and sanitary environment which promoted the prevention of the spread of infections when 2 of 2 sampled residents (Resident 1 and 2) had C-Diff infections, (C-Diff, a highly contagious bacteria in the intestines that could cause severe diarrhea, inflammation of the colon, abdominal discomfort, lack of appetite, weight loss, isolation, extended hospital stays, and/or death) and resided in a locked memory care unit for dementia (an enclosed living space for residents with dementia, a disease that caused an inability to think, reason, or remember) and; 1. [...]

Inspectors wroteThe following reflects the findings of the California Department of Public Health during an abbreviated standard survey for one facility reported incident. Facility Reported Incident: 867595 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the Department: 22705, Health Facilities Evaluator Nurse A deficiency was issued at F 557 for facility reported incident 867595. Based on observation, interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect, when Certified Nursing Assistant (CNA) A left Resident 1 alone in the dining room, unattended with the lights turned off, after dinner. This failure resulted in Resident 1 feeling rushed and had the potential to result in a decline in psychosocial well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Six dry storage bins had white and yellow-colored dried sticky substances on the lids and bottom of bins. 2. Five of the kitchen drawers had sawdust particles on the inside corners, six kitchen drawers had yellowish sticky food particles on the inside of the drawers which stored cooking utensils. 3. The kitchen microwave had yellowish food splatter on the inside including the top and both sides. 4. There was a wet dirty blue cloth stored under the cook preparation (prep) sink with visible black colored dirt and grime on the bottom of cabinet and covering the pipes. 5. The cooking utensils had dried food particles. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident grievances and complaints were promptly reviewed, investigated, resolved, and documented for 1 of 26 sampled residents. (Resident 75) This had the potential for quality of care issues and neglect to continue for all residents in the facility, which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of three sampled residents, (Resident 5 and Resident 182) were free from abuse and neglect when: 1. Resident 5 was verbally abused by her roommate, Resident 7. 2. A Licensed Nurse LN (A) was verbally rude, disrespectful, and did not provide care when requested for Resident 182. This failure caused Resident 7 and Resident 182 increased anxiety, loss of dignity, and humiliation.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the facility staff recognized and reported allegations of abuse for two of two sampled residents (Residents 5 and 7) within two-hours, when resident 7 was verbally abusive and threatened resident 5 on 04/25/23 at 2:38 am, and this was not reported until 05/04/23 at 2:40 pm, 15 days later. This failure had the potential to delay the identification, and implementation of appropriate corrective actions, and placed other facility residents at risk for potential abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a care plan for two of two sampled residents (Resident 5 and 7) was revised and updated to reflect an abuse allegation. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 4 of 26 sampled residents (Residents 75, 77, 181 and 182), received assistance with activities of daily living to attain or maintain their independence when: 1. Routine grooming activities were not completed for Resident 182. 2. Routine and scheduled showers and toileting were not completed for Residents 75, 77, 181 and 182. These failures had the potential to result in residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 26 sampled resident's environment was free from accident hazards when the facility equipment was stored in the resident's bedroom and the resident's assistive devices were moved out of her reach. (Resident 182) This failure had the potential to increase Resident 182's risk for fall and injuries and violated her right to have a homelike bedroom environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure competent nursing staff when: 1. The facility staff did not understand the different types of resident abuse and the abuse policy process or to whom they should report abuse to. 2. The facility staff did not know how to implement the facility's resident grievance process. 3. The facility staff did not know that translation services were available for residents who did not speak English. 4. Facility staff did not know the process for reporting missed resident showers. This failure to ensure competent staff for facility's abuse process resulted in alleged abuse not being reported to California Department of Public Health (CDPH), the Ombudsman (resident advocacy group) and the Police, and had the potential for grievances to go unresolved and for residents who did not speak English to not have their needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to identify the specific needs of and develop individualized plans of care for three of four sampled residents with dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) in order to promote a high quality of life. (Residents 77, 181 and 182). This has the potential for residents with dementia to have ongoing fear, anxiety, behaviors and injuries due to the facility not recognizing and analyzing interventions tailored to their specific needs and prevent those with dementia from attaining or maintaining their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that dietary staff had appropriate competencies to carry out the functions of food and nutrition services when two quaternary sanitizer (Quat, a solution used to sanitize kitchen work surfaces) buckets had not been changed for day shift, and when tested were not at the required concentration level for effectiveness for sanitizing surfaces in the kitchen. This failure had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) to all residents.