Health inspection·March 27, 2026

George Mee Memorial Hospital DP/SNF Provider Number: 056443 Citation "AA" Survey ID: 1E1408-H1 Intake Number: 2709157 REGULATORY VIOLATIONS: Code of Federal Regulations Title 42 §483.25 Quality of Care 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. California Code of Regulations Title 22 § 72311 - Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. California Code of Regulations Title 22 § 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. From 1/20/26 to 1/30/26, an unannounced visit was conducted at the facility for an annual federal recertification survey. During the survey an incident was reported to the state agency regarding Resident 45's elopement on 12/23/25. The facility failed to ensure the safety of Resident 45 who was at risk for elopement (the unauthorized, unsupervised departure of a patient/resident from a healthcare facility when their condition puts them at risk for injury or death) when: 1a. The facility failed to complete Resident 45's Elopement Evaluation Assessment (a formal assessment conducted by healthcare staff to determine the likelihood of a resident or patient leaving the premises without supervision or authorization) as ordered on 10/1/2025. 1b. The activity staff did not develop and implement Resident 45's care plan on his preference to have garden time independently, who was at risk for elopement if left unsupervised. 1c. The facility did not implement their Leave of Absence (LOA) policy and procedures (PnP) for Resident 45 when nurses did not complete and document Resident 45's mental, physical, and functional assessment prior to leaving the facility on several occasions when they left the facility on LOA. 1d. The facility staff failed to check Resident 45's whereabout when he was not seen in the skilled nursing unit on 12/23/2025 for about four hours (from 1:36 p.m. to 5:20 p.m.). These failures resulted in Resident 45's elopement on 12/23/2025, at 1:36 p.m., resulting in a motor vehicle accident on 12/23/2025, at 5:20 p.m., outside the facility's premises, and eventually Resident 45's death on 1/3/2026. FINDINGS: 1a. Review of Resident 45's face sheet indicated Resident 45 was admitted to the facility on 10/1/2025 with diagnoses including alcoholic cirrhosis (the permanent scarring of the liver, where healthy tissue is replaced by scar tissue, making it hard for the liver to function properly, leading to potential liver failure), alcohol dependence (also known as alcoholism, is the most serious form of drinking problem and describes a strong, often uncontrollable desire to drink), ascites of liver (abnormal buildup of fluid in the abdominal (belly) cavity, causing swelling, discomfort, and rapid weight gain) and hepatic encephalopathy (brain dysfunction caused by a failing liver that can't filter toxins leading to confusion, personality changes, memory issues, and in severe cases, coma or death). Review of Resident 45's quarterly minimum data set (MDS - a federally mandated resident assessment tool) dated 12/12/2025, indicated Resident 45's brief summary for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review of Resident 45's quarterly MDS revealed he was independent in transfers and walking. Review of Resident 45's clinical records indicated there was no Elopement Evaluation Assessment completed for Resident 45 upon admission. During an interview with SNF AM/MDSN on 1/22/2026, at 11:21 a.m., the SNF AM/MDSN stated that Resident 45 loved to walk and stay at the facility's garden. During a concurrent observation and interview with the DOQ on 1/22/2026, at 1:18 p.m., at the facility's rose garden, located at the ground level outside the facility, near the hospital's laboratory, there was a fence and two newly built gates around the rose garden area. The DOQ confirmed Resident 45 "eloped" on 12/23/2025 and that the new gates were installed after Resident 45's elopement and unfortunate death. During an interview with licensed vocational nurse (LVN) A on 1/22/2025, at 1:34 p.m., LVN A stated she was assigned as Resident 45's nurse before, but she could not recall the date. LVN A stated Resident 45 was at risk for elopement because there was one time, he left the facility at 8:00 a.m., and came back intoxicated, between 6:00 - 7:00 p.m. LVN A could not recall the date when this incident happened. LVN A stated the incident should have been reported to the management. LVN A further stated that it was hard to make sure Resident 45 was in the garden since nobody checked on him because he was responsible for himself. LVN A confirmed that Resident 45 was independent, but they (the facility) were still responsible for his safety. During an interview with licensed vocational nurse (LVN) B on 1/23/2026, at 9:57 a.m., LVN B stated they did not have a tool to assess if a resident was at risk of elopement and confirmed they did not complete the Elopement Evaluation Assessment for Resident 45. LVN B stated they never followed Resident 45 to the garden whenever he signed himself out. LVN B confirmed there were some access areas towards the exit doors on the way to the garden where Resident 45 could walk away from the facility without them knowing. During a follow-up interview with LVN A on 1/23/2026, at 2:45 p.m., LVN A stated that she did not witness the incident when Resident 45 returned from LOA intoxicated, but that one of the nurses told her about it. LVN A also stated, the scheduling coordinator (SC) had mentioned to her that when Resident 45 was sent to the emergency room on 12/23/2025, she (SC) found some bottles of alcohol inside his backpack. LVN A confirmed the bottles of alcohol were small and they called them, "shooters." During an interview with SNF NM on 1/26/2026, at 1:41 p.m., the SNF NM confirmed the Elopement Evaluation Assessment was not conducted for Resident 45 because he was alert, oriented and independent. He confirmed Resident 45 eloped on 12/23/2025 because he did not sign out when he left the facility after 1:00 p.m. The SNF NM stated that the nurse should have signed him back when he came back for lunch. He further stated, "I know there should be some changes." During an interview with the Medical Director (MD) on 1/26/2026, at 3:09 p.m., he stated that either his team or himself visited Resident 45 once a month or as needed. He ordered Resident 45 to go out on pass only with a responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action) for his safety. He stated Resident 45 was alert and oriented and had the free will to decide if he wanted to go out of the hospital premises or not. The MD confirmed he was called once in the past when Resident 45 came back from leave of absence and was intoxicated but could not recall the date. Review of Resident 45's physician order dated 10/1/2025, indicated an order, "Elopement Evaluation." Further review indicated a detailed order, "Leave of Absence...Constant order, resident can only leave SNF (hospital property) with responsible party [RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action]. NOT BY HIMSELF, Standard Precautions." Review of Resident 45's Release of Responsibility for Leave of Absence, dated 12/23/2025, indicated Resident 45 signed himself out at 10:28 a.m. to go to the "Garden." During a review of the facility's policy and procedure titled, "Code Green - Elopement," date revised 12/2022, indicated, "High-Risk Patient for Elopement / Patient Elopement: A patient who fits the following criteria or who leaves the patient care unit without permission who is: • Confused, disoriented or otherwise appearing to lack mental capacity..." 1b. Review of Resident 45's list of preferred activities dated 12/11/2025, indicated, "patient prefers to sign out for garden time...Garden time 5-7x [times]/ [per]week." A review of Resident 45's list of care plans indicated there was no activity care plan related to Resident 45's preferred activity of garden time which should have indicated that supervision was required as well as identifying the frequency of his whereabouts. During a concurrent interview and record review with LVN A on 1/22/2026, at 1:40 p.m., LVN A reviewed Resident 45's list of activity preferences dated 12/11/2025 and confirmed Resident 45 preferred to spend time in the garden as indicated in Resident 45's preferred activity list. LVN A stated Resident 45's preference should have been care- planned. LVN A further stated, a care plan should have goals and interventions. During a concurrent interview and record review with activities coordinator (AC) on 1/23/2026, at 9:41 a.m., the AC reviewed Resident 45's list of care plans and she confirmed the care plan that was developed was not considered a care plan. She stated Resident 45's preference regarding garden time did not include the objectives and interventions specific for Resident 45. She stated a care plan should have objectives and interventions. The AC also stated there was no constant monitoring of Resident 45's whereabouts during garden time and this should have been one of the interventions if the care plan was developed. During an interview with LVN B on 1/23/2026, at 9:57 a.m., LVN B stated there should have been a care plan about Resident 45's preference of garden time and how to keep him safe. During a review of the facility's policy and procedure titled, "Interdisciplinary Plan for Care," date revised 11/2019, indicated, "It is the policy of Mee Memorial Hospital Skilled Nursing Facility that the interdisciplinary team develop a comprehensive assessment and Care Plan for each resident...The assessment and Care Plan are developed by an interdisciplinary team which includes, but is not necessarily limited to:...5. Activities Coordinator." 1c. Review of Resident 45's clinical record titled, "Release of Responsibility for Leave of Absence," dated: • 12/1/2025 - indicated Resident 45 signed himself out to go to the "garden" at 12:48 p.m., no documented "Time in." • 12/2/2025 - indicated Resident 45 signed himself out to go to the "garden" at 1:35 p.m., no documented "Time in," and had no nurse initials. • 12/3/2025 - indicated Resident 45 signed himself out to go to the "garden" at 2:20 p.m., and no documented "Time in." • 12/4/2025 - indicated Resident 45 signed himself out to go to the "garden" at 1:30 p.m., and no documented "Time in." • 12/6/2025 - indicated Resident 45 was signed out by a friend at 8:50 a.m., the destination was left blank and there was no documented "Time in." • 12/7/2025 - indicated Resident 45 was signed out by a friend at 9:30 a.m., the destination indicated, "out," there was no documented "Time in," and no nurse initials. • 12/9/2025 - indicated Resident 45 signed himself out at 1:36 p.m., the destination indicated, "out" and there was no documented "Time in." • 12/10/2025 - indicated Resident 45 signed himself out at 1:00 p.m., "Time in" indicated 5:35 p.m., the destination was "out," and no nurse initials. • 12/11/2025 - indicated Resident 45 signed himself out at 2:54 p.m., no "Time in" documented, and the destination was "out." • 12/12/2025 - indicated Resident 45 signed himself out to go to the "Garden," at 12:33 p.m., and no documented "Time in." • 12/13/2025 - indicated Resident 45 signed himself out to go to the "Garden," at 12:43 p.m., and he was back at 5:25 p.m. • 12/15/2025 - indicated Resident 45 signed himself out to go, "outside," at 1:56 p.m., and he was back 5:21 p.m. • 12/16/2025 - indicated Resident 45 signed himself out to go, "outside," at 12:21 p.m., and he was back at 5:33 p.m. • 12/17/2025 - indicated Resident 45 signed himself out to go to the "garden," at 2:00 p.m., and there was no documented "Time in." • 12/18/2025 - indicated Resident 45 signed himself out to go "Downstairs," at 10:53 a.m., and there was no documented "Time in." • 12/19/2025 - indicated Resident 45 was signed out by a friend to go to "town," at 11:19 a.m. and with "Time in" at 5:50 p.m. • 12/20/2025 - indicated Resident 45 signed himself out at 1:20 p.m., the documented destination was not legible, and there was no documented, "Time in." • 12/21/2025 - indicated Resident 45 was signed out by a friend at 8:40 a.m., no documented destination, no "Time in," and no nurse initials. • 12/22/2025 - indicated Resident 45 signed himself out to go to the "Garden," at 12:30 p.m., and no documented "Time in." and • 12/23/2025 - indicated, "Time out, 1028; Time in LOA - 1740 (military time for 5:40 p.m.), Destination: Garden," signed by Resident 45. During an interview with SNF NM on 1/22/2026, at 4:44 p.m., the SNF NM stated he did not get any report when Resident 45 came back intoxicated. The SNF NM stated the receptionist seated at the first-floor lobby, near the elevator (access to go to SNF - second floor) was just temporary. The SNF NM further stated they never checked who was leaving the SNF. During a concurrent interview and record review with SNF NM on 1/23/2026, at 1:34 p.m., the SNF NM reviewed Resident 45's December 2025 nurse's notes and confirmed that the nurses did not complete and document Resident 45's assessment prior to leaving and upon returning to the facility. The SNF NM stated the nurses should have assessed Resident 45 first before he left and when he came back to the facility. He confirmed that when Resident 45 signed out to the garden, it was considered LOA and he had a choice to leave the facility premises while he was at the garden. The SNF NM stated it was his understanding that when Resident 45 signed himself out, it would release them (the facility) of their responsibilities to Resident 45. The SNF NM further stated that when Resident 45 went out of the facility's premises, he needed to have an RP to sign him out because Resident 45 had a history when he associated himself with some "undesirable people." The SNF NM confirmed that the nurse's December 2025 progress notes did not indicate assessments were completed before Resident 45 left and when he came back to the facility on the following dates: 12/1/2025 to 12/4/2025, 12/6, 12/7, 12/9, 12/10, 12/11, 12/12, 12/13, 12/15/20225 to 12/23/2025. During a review of the facility's policy and procedure titled, "Patient Leave of Absence," date revised 8/2022, indicated, "Leave of Absence (LOA): Any absence from the facility. If the patient is not present for the midnight census count, he/she is placed on a bedhold... For all patients going on a "Leave of Absence" (LOA) the criteria below must be met: •