Health inspection·September 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. And Resident 2 eloping from the facility and being found by law enforcement at a gas station four-tenths of a mile away, in the middle of the night. Findings: A review of the facility ' s policy titled, Elopement Policy, dated 5/8/24, indicated that the facility must Complete an elopement risk assessment upon admission ., and Identify residents who wander and/or who are at risk for elopement . A review of the facility ' s policy titled, Wandering Resident Protocol, dated 12/21/22, indicated that, Each new patient should be evaluated as to whether or not he/she presents a wandering risk. All patients, at any time, should be observed and evaluated as being a wandering risk, and If evaluation indicates the patient is at risk for wandering, use of the Wanderguard signaling device [a device that alarms and alerts staff when the resident exits through a facility door] as recommended. Review of Resident 1 ' s face sheet indicated that he was admitted to the facility on [DATE] with a diagnosis of anoxic brain injury (when the brain does not get oxygen causing brain cell death and problems with thinking and decision making). Record review of Resident 1 ' s Brief Interview for Mental Status (BIMS, a screening tool used to identify cognitive conditions) indicated a score of 3 (a score of 0-7 suggests severe cognitive impairment). Record review of Resident 1 ' s progress notes for 8/18/24 indicated he was found unharmed in the parking lot of the facility at 1:35 PM, the facility did not know when or through which door he exited, he stated to staff that he was looking for a cigarette. The progress note indicated that Resident 1 was wearing a Wander Guard and that the Wander Guard was functioning that day. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056416 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mayers Memorial Hospital 43563 Hwy 299 E Fall River Mills, CA 96028 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)