Health inspection·June 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 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. Findings: A review of the facility's policy titled, FALLS-SNF (Skilled Nursing Facility) dated 5/22/23, indicated that a fall is an unplanned descent to the floor which may either be observed or unobserved. The policy indicated the facility is committed to maintaining resident safety by identifying those residents who are at risk for falls, at high risk of injury from falls and implement evidence-based interventions to prevent falls and injury. For residents identified as at risk for falls, the policy indicated that the facility would implement fall prevention measures such as addressing fall risks on the residents' care plan and providing non-skid footwear or shoes. A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (memory and decision-making problems), rheumatoid arthritis (arthritis that deforms joints), prostate cancer, vision problems, and high blood pressure. A review of Resident 1's Morse Fall Scale (a fall risk assessment with scores of High Risk-45 or higher, Moderate Risk-25 to 44, and Low Risk- 0 to 25), dated 1/18/24, 3/19/24, 8/24/24, and 10/4/24, was conducted. Resident 1 was at a high risk for falls with a score of 90, due to a history of falls, severe cognitive impairment (ability to remember and make sound decisions), impulsiveness (acts before thinking about the consequences), poor safety awareness, poor vision, and balance problems while sitting and walking. A review of Resident 1's post fall Nursing Notes indicated that on: (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 4 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 06/20/2025 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)