Health inspection·August 7, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents are not stuck in their rooms. The cords can be a safety concern sometimes, like in the dining room.During an interview on 8/6/25 at 08:45 am, with [NAME] Clerk (WCL) G at the nurse' station, WCL G stated, I have been here since 6/11/25 and I know I have called the oxygen service provider to send a technician out at least 6 times since I started. It is frequent. They were supposed to come out on Friday 8/1/25, and just did not show up. I had to call on Monday 8/4/25, the provider was not aware that the technician did not show up. A lot of our residents go out of the facility with their families. When no portable oxygen tank is available, the family activities are curtailed, and some residents stay in their rooms because they do not want to drag the concentrators around.During an interview on 8/6/25 at 9:00 am, with Assistant Director of Nursing (ADON) B, outside the facility by the laundry building, ADON confirmed the concentrators have had to be fixed multiple times in addition to problems with operator errors. We have had technicians out quite a bit to fix different issues with the large concentrators. When the concentrators don't work the portable tanks cannot be filled, so the residents have to use either their room oxygen, or concentrators which must be plugged in to the electric outlets to work. Residents do need assistance to take the concentrator machine unit where there is an electrical outlet. This can be a problem for the residents because of the machine's size, and the potential safety concern with the cord. Event ID: Facility ID: 056416 If continuation sheet Page 2 of 14 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 08/07/2025 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. FM H stated, “Have you looked at the bathroom? It is disgusting.” Resident restroom [ROOM NUMBER] was observed to have a gap around the toilet base and the linoleum where the caulking (a waterproof filler or sealant used to seal cracks or gaps to prevent buildup and water damage), was torn and missing, grime had collected in the gap resulting in discolored buildup, which appeared to be dirty with the resemblance of urine or fecal matter buildup. In general, the linoleum was old, scratched up, and in disrepair. FM H stated, “I want it to be homelike here, and I would never allow my home restroom to look like this.” During an observation on 8/5/25 at 4:30 pm, in resident restroom [ROOM NUMBER], there was a gap between the linoleum and the toilet base with torn or missing caulking. The discolored buildup in the gap resembled dried urine or fecal matter. During an observation and interview on 8/6/25 at 9:30 am, with Assistant Director of Nursing (ADON) B, in resident restroom [ROOM NUMBER], the linoleum gap around the toilet with torn caulking and discolored buildup was observed, as well as the condition of the linoleum on the floor. ADON B confirmed the bathroom was is not in acceptable condition. During an interview on 8/6/25 at 11:45 am, with Environmental Services Manager (EVM) in ADON B's office, EVM stated,We know there are issues with floor disrepair and are working on them. During a review of the facility’s document titled, Housekeeping Principles,” with an effective date of 4/25/19, indicated the facility, “promotes a sanitary environment by incorporating infection control principles into housekeeping practices”. In the section titled, Procedure: Frictional Cleaning”, indicated, “Thorough scrubbing is used for all environmental surfaces that are cleaned in patient care areas”. The policy continues in the section, “Routine Cleaning of Horizontal Surfaces”, “…cleaning of non-carpeted floors and other horizontal surfaces is done daily and or frequently if spillage or visible soiling occurs”. During an observation on 8/4/25 at 1:44 pm, in resident restroom [ROOM NUMBER], the base of the toilet had dark grime collected resulting in discolored buildup on the caulking, which appeared to resemble dried urine. During an observation on 8/4/25 at 2:20 pm, in resident restroom [ROOM NUMBER], the base of the toilet was missing caulking, and had dark grime and loose dirt debris that encircled the base of the toilet. The floor had grime buildup, loose dirt debris, and a black scuff mark. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 3 of 14 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 08/07/2025 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 8/4/25 at 2:25 pm, in resident restroom [ROOM NUMBER], the caulking at the base of the toilet was chipped and had yellow staining, which appeared to resemble dried urine. Caulking was partially missing from the base of the toilet and had a buildup of grime and loose dirt debris. The floor had dark grime buildup, loose dirt debris, and black scuff marks. During an observation on 8/4/25 at 2:27 pm, in resident restroom [ROOM NUMBER], the base of the toilet had grime collected resulting in discolored buildup on the caulking, which appeared to resemble dried urine. The floor had dark grime buildup and loose dirt debris. During an interview in the hallway with Licensed Vocational Nurse (LVN) I on 8/6/25 at 7:36 am, when asked about the resident restrooms on the unit, LVN I confirmed the condition of the restrooms on the unit were, “not good and are unsanitary. My bathroom would not look like this”. During an interview with the Assistant Director of Nursing (ADON) B in the office on 8/6/25 at 10:14 am, when asked about the condition of the resident restrooms, the ADON B confirmed the restrooms had, “inadequate maintenance and they need to be addressed”. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 4 of 14 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 08/07/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based 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; motor and sensory instability (unreliable thinking and ability to move), dizziness, drowsiness, increased risk of falls and fractures, and death caused by heart problems. Findings: Review of the facility's policy titled, Residents with Dementia Antipsychotic Medication indicated: 1a.: The physician in conjunction with the interdisciplinary team (IDT) will add resident-specific, non-pharmacological (non drug) interventions upon admission, and routinely throughout therapy when needed and; 1b.: The IDT will continue to follow the specific non-pharmacological interventions to make sure they are the best fit for the resident. This will be done at least monthly. and;2. Upon initiation of an antipsychotic medication for a resident with a diagnosis of dementia [age-related decline in brain function], the Charge LVN will obtain from the physician an approved diagnosis for the antipsychotic medication and specific behaviors for its use. Whenever there is a change in the resident's medical condition or medical status, the consultant pharmacy, at the bequest of the facility, will review the resident's current medications. The consultant pharmacist will then recommend to the physician any specific dose reductions, additions/changes, and or discontinuations, based on need, labs, and the current dose.Clinical record review indicated Resident 3 was admitted for medical conditions that included unspecified dementia, chronic kidney disease, and emphysema (loss of ability of lungs to expand). Review of resident 3's physician orders indicated that on 6/17/25, his physician ordered Rexulti (brexpiprazole, an antipsychotic medication) for agitation, (undefined) related to unspecified dementia, unspecified severity, with other behavioral disturbances, which were also further undefined. Resident 3's physician orders indicated that he first received Rexulti on 5/10/25 for agitation which had not specified the specific target behavior or symptom.Review of Resident 3's care plan dated 5/12/25, indicated that resident had, an alteration in mood and behavior related to dementia as evidenced by physical aggression toward staff and peers, including verbal aggression and agitation toward staff/peers. The terms aggression and agitation were undefined, without example, creating a potential for subjective interpretation by various staff assessing Resident 3's behavior. Resident 3's care plan indicated an absence of non-pharmacologic approaches other than general statements such as anticipate the resident's needs, and approach the resident in a calm manner. Review of Resident 3's electronic medication administration record (eMAR) dated 5/11/25, indicated that Behavior Monitoring was constituted by verbal aggression, and agitation without further definition or examples of aggressive or agitated acts. Review of Interdisciplinary Team (IDT, a group of facility managers who oversee resident care) notes dated 7/1/25, had not addressed Resident 3's use of Rexulti. There was no discussion of what target symptoms the antipsychotic medication was prescribed for or what the expected risks and benefits were for Resident 3 by using this medication.Review of progress notes entered by Charge LVN (LN C) on 6/05/25 at 8:42 am, indicated only broad examples of aggression, which were mainly toward staff. LVN C indicated in that progress note that Rexulti may have been an inappropriate medication for Resident 3, Resident continues to have aggressive behaviors towards (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 5 of 14 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 08/07/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff and peers. This morning resident got agitated that another resident was calling out to go to the restroom. Making threatening statements towards nursing staff stating he was going to fight the nurse and take care of him. These behaviors seem to continue to worsen and is becoming a safety issue for not only other residents but staff as well. Rexulti seems to be ineffective at this time.During a concurrent interview and observation on 8/5/25 at 9:15 am, of Resident 3 stated that he had problems with roommates he has had and, the alarms that were going off all the time. He appeared unkept, had long uncombed hair, and had difficulty communicating clearly. He currently had no roommate. In an interview on 8/6/25 at 10:57 am, LVN C stated that she couldn't recall any non-pharmacologic interventions for Resident 3. LVN C stated that Resident 3 was new, and that she was the charge nurse helping staff contact the medical provider about the resident's behaviors of throwing objects and threatening his roommates. She stated the as she recalls it, the provider just put in the order, but she couldn't recall what staff might have tried otherwise before starting an antipsychotic drug. LVN C stated that Resident 3 had received a dose of Clonidine (a blood pressure medicine) that was abruptly stopped; Resident 3's provider suspected it could have had an interaction with other medication and caused Resident 3's agitation. LVN C stated that Rexulti was ordered and started around the same time as stopping Clonidine, which made it difficult to asses what the Rexulti was actually contributing to the medication mix. LVN C confirmed that using the antipsychotic was aggressive, adding, there were other things that staff could try before aggressive treatment.Record review indicated Resident 5 was admitted to the facility for medical conditions that included a history of stroke, unspecified dementia, nerve pain, weakness, and need for assistance. Review of Resident 5's physician orders indicated that her physician ordered Rexulti 0.5 milligrams (mg, a unit of measure) by mouth once daily, on 1/22/25, for agitation related to dementia. No further definition of agitation was described. Resident 5's physician orders indicated that on 3/26/25 Resident 5's dose of Rexulti was increased to 1 mg, and that the medication was discontinued 5/14/25, and restarted as 0.5 mg on 5/28/25, at the recommendation of the resident's daughter.Review of IDT notes had not addressed Resident 5's use of Rexulti. There was no discussion of what target symptoms the antipsychotic medication was prescribed for or what the expected risks and benefits were for Resident 5, by using this medication.Resident 5's record titled, Order Summary dated 5/28/25 indicated, Monitor for the following behaviors: A) Verbal aggression toward staff and others; B) Physical aggression toward staff and others. There were no defining characteristics of verbal or physical aggression. Review of Resident 5's care plan dated 1/22/25 through 7/21/25, indicated Rexulti as the first intervention for the Resident 5's behavior of, Aggressive documented episodes with her roommates, Anger, Poor impulse control, and Attempt at leaving the facility unassisted. No nonpharmacologic approaches were included on the care plan. In an interview and observation on 8/4/25 at 3:30 pm, Resident 5 was observed to be socializing in activities and stated she doesn't need any medication, she's fine.In an interview on 8/5/25 at 12:44 pm, LVN B stated that Resident 5 received Rexulti after she had episodes of aggression toward others and staff, mostly consisting of threatening her roommate, hostility toward her granddaughter, and refusing showers and washing hair. In an interview and concurrent review on 8/5/25 at 3:21, with the Director of Nursing (DON), the DON confirmed that behaviors listed as aggressive could be more specific. DON confirmed that Resident 3 and 5's IDT notes had not addressed the use of Rexulti or included specific target behaviors, non-pharmacological interventions to be tried, and what the expected risks and benefits were for the use of the antipsychotic medication in accordance with the facility's policy, and should have.Review of Resident 29's clinical record indicated that he was admitted to the facility for conditions that included dementia and a need for staff assistance in carrying out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 6 of 14 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 08/07/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete activities of daily living. A review of Resident 29's physician's orders indicated that on 4/28/25 an order was entered by his physician for Zyprexa (olanzapine, an antipsychotic drug), Oral Tablet 5 mg, once daily at bedtime for aggressive behaviors related to dementia. A review of 29's e-MAR from January to July 2025, indicated that the facility had not monitored any behaviors for the use of Zyprexa for Resident 29.A review of Resident 29's pharmacist drug regimen review (DRR) dated June 2025, indicated the Pharmacist's (PHARM) documented, Contacted provider.Resident has no charted behaviors for at least 120 days at time of review. OBRA F329 (federal Omnibus Reconciliation Act, a federal act that impacts use of antipsychotics) states that the lowest effective dose of antipsychotics should be used to control symptoms. Please evaluate a trail of a lower dose would be indicated. If dose not reduced, please work with nursing staff on targeted behaviors. The record further indicated that this was the pharmacist's fourth month in a row this recommendation was made without Resident 29's physician responding. The PHARM DRR also included that Buspar (an antianxiety medication) had no behavior monitoring and documented, Resident has had minimal behaviors charted for Buspar in May. None in June at time of review. Please evaluate. If dose reduction not indicated, please work with nursing staff to target behaviors. The DRR indicated Resident 29's physician had not responded to this review since May 2025, a period of three months.In an interview DON on 8/6/26 at 2:46 pm, and concurrent review of Resident 29's care plan , DON stated, Non-pharmacologic approaches appears to be none. She confirmed that the documentation was not adequate for justification of using an antipsychotic, and that there should be more specific about behaviors.In an interview and concurrent record review on 8/7/25 at 9:00 am, PHARM confirmed that he had reviewed all of the above medications. PHARM stated that Rexulti is a medication specific to agitation and aggressiveness in patients with dementia. Pharmacist stated, When I reviewed these orders, I looked at specific instances of agitation and aggression that could be harmful to the resident or others. PHARM confirmed that he reminded the DON and nursing staff that the documentation of behaviors over the last 120 days of his review needed to be more specific to meet the standard of using an antipsychotic in a skilled nursing setting. PHARM confirmed that his request to consider Gradual Dose Reduction (GDR) for Resident 29 had carried over four months in a row unaddressed by Resident 29's physician. PHARM stated that Resident 29 was declining as would be expected with his disease, but at this point Resident 29 was almost nonverbal (unable to speak), so many of the behaviors he may have had in the past may not be continuing as he becomes more incapacitated. PHARM added that the use of antipsychotic medications in the elderly has been associated with falls and poor clinical outcomes, and that doses should be continuously evaluated throughout their disease progression. Event ID: Facility ID: 056416 If continuation sheet Page 7 of 14 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 08/07/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. CN A acknowledged it was a mistake.During an interview on 8/4/25 at 1:32 p.m. with the Director of Nursing (DON), the DON stated, I see the potential that someone can come and switch out the tag. The code on the lock should match with the record to minimize the risk of drug diversion.Review of the facility policy and procedure titled, discontinued Medications and Controlled Substance Disposal, dated 4/24/25, indicated, [NAME] Memorial Hospital District's Skilled Nursing Facility handles discontinued medications in a secure, safe, and legal manner. Event ID: Facility ID: 056416 If continuation sheet Page 8 of 14 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 08/07/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This 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. Findings: Review of the facility's policy titled, Residents with Dementia Antipsychotic Medication, dated 6/18/24, indicated, Whenever there is a change in the resident's medical condition or medical status, the consultant pharmacy, at the bequest of the facility, will review the resident's current medications. The consultant pharmacist will then recommend to the physician any specific dose reductions, additions/changes, and or discontinuations, based on need, labs, and the current dose. The physician will review the dosage recommendations and determine at such time if a dose adjustment is medically indicated or clinically contraindicated [not necessary]. The reason for the medication to continue to be medically indicated will be answered in the response section on the consultant's recommendation or in the physicians' progress note.Clinical record review indicated Resident 3 was admitted for medical conditions that included unspecified dementia, chronic kidney disease, and emphysema (loss of ability of lungs to expand).Review of resident 3's physician orders indicated that on 6/17/25 his physician ordered Rexulti (brexpiprazole, an antipsychotic medication that alters thinking or behavior disturbances) for agitation. Review of Resident 3's monthly Pharmacy Medication Regimen Review (MRR) records dated 1/25 to 7/25/25, indicated no signature or response to the Pharmacist's recommendations from Resident 's physician, from 3/25/25 to present, a period of five months. Clinical record review indicated Resident 5 was admitted to the facility for medical conditions that included a history of stroke, unspecified dementia, nerve pain, weakness, and need for assistance with activities of daily living.Review of Resident 5's physician orders indicated that her physician ordered Rexulti 0.5 milligrams (mg, a unit of measure) by mouth once daily on 1/22/25, for agitation related to dementia.A review of the, Beers Criteria for Potentially Inappropriate Medications, a set of guidelines developed by the American Geriatrics Society, indicated Antipsychotics as a class of medications that have the potential to be unsafe in patients greater than [AGE] years old. Review of Resident 5's MRR's dated 1/25 to 7/25/25 indicated that in January, PHARM indicated to the provider, The combination of gabapentin [a nerve pain medicine] and an opioid (a strong narcotic pain medicine), was a high risk combination per the Beers list. Please document a risk benefit analysis that addresses risk of fall/fracture and respiratory depression. Gabapentin is ordered for nerve pain in back. Is it effective? Nerve pain in back is an off-label use. Resident 5's physician had not responded to PHARM's recommendations for 10 months. Review of Resident 29's clinical record indicated that he was admitted to the facility for conditions that included dementia and a need for assistance in his activities of daily living.A review of Resident 29's orders indicated that on 4/28/25 an order was entered by his physician for Zyprexa (olanzapine, an antipsychotic medication), Oral Tablet, 5 mg per day, for aggressive behaviors related to dementia.A review of Resident 29's MRR dated June 2025, indicated the Pharmacist's (PHARM) comments: Contacted provider.Resident has no charted behaviors for at least 120 days at time of review. OBRA F329 (federal Omnibus Reconciliation Act, a federal act that impacts use of antipsychotics) states that the lowest effective dose of antipsychotics should be used to control symptoms. Please evaluate a trail of a lower dose would be indicated. If dose not reduced, please work with nursing staff on targeted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 9 of 14 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 08/07/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete behaviors. The record further indicated that this was the pharmacist's fourth month in a row this recommendation continued. Resident 29's June 2025 MRR also indicated concerns for behavior documentation for the use of Buspar (an antianxiety medication), Resident has had minimal behaviors charted for Buspar in May. None in June at time of review. Please evaluate. If dose reduction not indicated, please work with nursing staff to target behaviors. No response was indicated in the physician's signature line.In an interview and concurrent record review on 8/7/25 at 9:00 am, PHARM confirmed that he had reviewed all of the above medications for Resident 29. PHARM confirmed that he reminded the DON and nursing staff that the documentation of behaviors for antipsychotics needed to be more specific to meet the standard of using an antipsychotic in a skilled nursing setting. PHARM confirmed that his request to consider Gradual Dose Reduction (GDR) for Resident 29 had carried over four months in a row unaddressed by the Physician, DON, and nursing staff. Event ID: Facility ID: 056416 If continuation sheet Page 10 of 14 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 08/07/2025 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based 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. During an observation of medication administration on 8/5/25 at 7:05 a.m., Licensed Nurse (LN) B was observed to prepare and administer Resident 40's morning medications which did not include Resident 40's doxycycline. During an interview on 8/5/25 at 7:10 a.m. with LN B, LN B stated, doxycycline was not available. Resident ran out short somehow, and I don't know why. Reconciliation of the observation of medication administration with Resident 40's current Physician Orders indicated an order, dated 7/30/25, doxycycline oral tablet, 100 mg (milligram, unit of measurement) by mouth two times a day for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) until 8/8/25. During an interview on 8/5/25 at 7:35 a.m. with the Charge Nurse (CN), the CN stated, RX [prescription] got extended by the provider, but the medication was still not received from the pharmacy. During another interview on 8/5/25 at 7:38 a.m. with LN B, LN B stated, the dose was just taken out of the emergency medication box and administered.During another interview on 8/5/25 at 11:59 a.m. with the CN, the CN stated, the pharmacy was contacted to follow up on the missing doses of doxycycline. During an interview on 8/5/2025 at 12:07 p.m. with the Director of Nursing (DON), the DON stated, the expectation is to have the full dose of medication available for medication administration. If short [the quantity], the pharmacy needs to send the remaining quantity in a timely manner. A review of facility policy titled, Administering Medications, dated 9/2023, indicated Medications and treatment shall be administered as prescribed.retrieve medication from patient medication drawer.2. During an observation of medication administration on 8/5/25 at 7:58 a.m., LN B was observed to prepare and administer Resident 4's morning medications which included Resident 4's omeprazole. All medications were given together. Breakfast was already served and Resident 4 had consumed approximately 1/2 of his breakfast. Reconciliation of the observation of medication administration with Resident 4's current Physician Orders indicated an order, dated 5/17/25, for omeprazole oral capsule delayed release 20 mg, give 1 capsule by mouth two times a day for GI (gastrointestinal) protection give on empty stomach before breakfast. During an interview on 8/5/25 at 11:55 a.m. with LN B, the LN B stated according to the Physician Orders, Resident's omeprazole should have been given on empty stomach to protect Resident's stomach. Omeprazole was given to Resident after breakfast. LN B stated the order summary on the MAR (Medication Administration Record) did not match with the prescription label.During an interview on 8/5/25 at 12:10 p.m. with the DON, the DON stated, the nurses are expected to follow the Physician Orders. The nurses should make sure the MAR and Physician Order match. The MAR should have been updated to administer Resident's omeprazole to 7 a.m. allowing the nurse to have enough time to administer the medication before breakfast.A review of facility policy and procedure (P&P) titled, Administering Medications, dated 9/2023, the P&P indicated Medications and treatment shall be administered as prescribed.The 6 rights.the Right drug: read re-read med [medication] orders and drug label.the Right Time: times given are correct .recheck EMAR [Electronic Medication Administration Record] and medication bottle labels to insure patient name, medication, and directions match. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 11 of 14 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 08/07/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based 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. with LN A , LN A acknowledged that the insulin pen was expired and needed to be removed from the refrigerator. LN A stated, “expired medications will have reduced efficacy.” During a review of insulin lispro’s Provider Information (PI), last revised 9/2023, the PI indicated, “Do not use insulin lispro past the expiration date printed on the label .Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.” During an interview on 8/4/25 at 1:35 p.m. with the Director of Nursing (DON), the DON stated, the nurses should be checking for outdates every time they take over the cart. The insulin pens should be dated and replaced when they are expired. expired medications will not be effective. Review of the facility policy and procedure (P&P) titled, “Medication Procurement, Storage & Security” dated 3/2025, the P&P stated, “Drugs and biologicals are stored under the conditions recommended by the manufacturer…medications with shortened expiration dates are labeled with the new expiration date after first use. Example include insulin…outdated medications are removed from drug storage areas monthly…outdated, mislabeled, recalled, or otherwise unusable drugs and biologicals are not available for patient use and are stored separately…” 2. During an inspection of medication room B’s refrigerator on 8/4/25 at 8:43 a.m. with Assistant Director of Nursing (ADON) B, an expired 5 ml multi-dose vial of tuberculin purified protein derivative testing agent was found with “open date of 5/22/25” and “discard after 6/21/25” on the label. A review of the label on the product box indicated, “Discard opened product after 30 days.” During an interview on 8/4/25 at 8:54 a.m. with ADON B, ADON B confirmed that the tuberculin purified protein derivative testing agent was expired and needed to be removed from the refrigerator. ADON B stated, “It should have been removed from the active medication storage. The expired medication could be less effective and dangerous for a resident.” Review of the facility P&P titled, “Medication Procurement, Storage & Security” dated 3/2025, the P&P stated, “Drugs and biologicals are stored under the conditions recommended by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 12 of 14 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 08/07/2025 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)

F 0761 the manufacturer…outdated, mislabeled, recalled, or otherwise unusable drugs and biologicals are not available for patient use and are stored separately…” Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 13 of 14 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 08/07/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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.During a medication pass observation with LN A on 8/5/25 at 7:28 a.m., LN A used the same blood pressure monitor to measure Resident 13's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident's room and placed on the medication cart without being cleaned and disinfected.During a medication pass observation with LN A on 8/5/25 at 7:45 a.m., LN A used the same blood pressure monitor to measure Resident 2's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident's room and placed on the medication cart without being cleaned and disinfected.During an interview with LN A on 8/5/25 at 8:25 a.m., LN A acknowledged that the blood pressure monitor and cuffs were not cleaned and sanitized between patients. LN 1 stated, ideally blood pressure monitor and cuffs could be wiped to reduce risk of infection.During an interview with Director of Nursing (DON) on 8/5/25 at 12:12 p.m., the DON stated, the blood pressure monitor and cuffs needed to be sanitized and disinfected between each resident to reduce risk of infection.During a review of the facility's policy and procedure (P&P) titled, Cleaning, disinfecting, and Sterilization, dated 5/2021, the P&P indicated, The following guidelines are general rules for ensuring that supplies and equipment are adequately cleaned, disinfected or sterilized. Specific policies for high-level disinfection or sterilization are maintained by the respective department.personal must have proper training on processing instruments (through either sterilization or high level disinfection) with competency testing upon hire, annually and periodically as needed.During a review of facility provided document by the DON on 8/5/25 t 4:36 p.m., untitled, the document stated, cleaning recommendations for your [brand name] wrist blood pressure monitor are important to maintain its hygiene.Monitor Casing: use a soft, dry cloth or a cloth dampened with water and a mild detergent to clean the monitor's exterior surface.Cuff: similar to the monitor casing, clean the cuff with a soft, moistened cloth and a mild, neutral detergent.regularly clean your blood pressure monitor to maintain accuracy and hygiene. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056416 If continuation sheet Page 14 of 14