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Mayers Memorial Hospital D/P SNF : citations
 

about citations

Under state law, a California nursing home can receive a citation and fine for certain violations of the law. Most nursing homes do not receive citations. In a typical year, less than 40% of California's nursing homes receive citations.

Citations are only issued for serious violations. You should be concerned if a nursing home is issued multiple citations in a brief period of time. However, it is also important to look at the nature of the citation. Some citations may indicate facility-wide problems or demonstrate failures to meet a particular care need.

Citations, while serious, should also be put into perspective. A single citation does not necessarily mean that a nursing home will provide poor care. Review the facility's deficiencies and complaints, as well as enforcement actions to see if there is a pattern of violations or if the facility has a fairly good record.

A change of ownership or management can quickly change the quality of care in a facility. Look to see which citations, if any, were acquired under the current owner.

The description for each citation lists the date that it was issued, the class of the citation, the CANHR category, the DPH category, and the amount of the fine. This information is followed by a brief summary of the citation prepared by CANHR.

At the end of each citation description is a citation number. If you want a copy of the actual citation, you will need to request it by citation number. Copies of citations can be obtained at the DPH District Office in the district where the facility is located. (link to DPH L&C district offices)


Includes Citations received by CANHR as of 7/8/2015

summary of citations by year

Citations

2011 
2012 
2013 
2014 
2015 
AA
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0
0
0
0
A
0
0
0
0
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B
1
1
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1
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description of each citation
details
date
class
canhr category type
DHS category
fine
03/05/2014  Physical Abuse  Patient Care 

  $2,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 11/12/13, a CNA witnessed another CNA place his hands on a resident's chest and forcefully push the resident down onto his bed. The facility was cited for failure to ensure the resident was free from physical abuse. Citation # 230010288.

10/16/2012  Patient Care Physical Abuse Verbal Abuse  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
The facility was cited for failing to ensure that a resident was not physically or mentally abused when two CNAs used profane language, pulled the resident's arm, and spoke to the resident in a demeaning manner. The CNAs then proceeded to pull the call light cord from the wall so that the resident could not call for help. Citation # 230009377.

10/18/2011  Fiduciary Mandated Reporting  Failure to Report 

  $750.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 7/9/11, a resident informed the nurse that $116 was missing from her wallet. The nurse completed an internal form and delivered the form to the administration office. The Department of Public Health was not notified until 7/18/11, nine days later. The facility was cited for failure to report the incident of alleged financial abuse to DPH within 24 hours, as required by law. Citation # 230008641.

01/29/2010  AA  Dietary Services Injury Neglect  Patient Care 

  $50,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 3/24/09, a resident who suffered from dementia choked on a sandwich, aspirated, and died five days later of aspiration pneumonia and respiratory failure. The resident's physician had ordered his food to be ground because he was missing most of his teeth and had a swallowing problem. The facility ignored this order when a staff member gave him a meat and cheese sandwich shortly after midnight on 3/24. Paramedics were called when the resident began choking and found that his airway was obstructed by large pieces of meat from the sandwich. He was transferred to the hospital, where he died. The facility was cited because its failure to follow his special diet led to his death. Citation # 230006952.

10/21/2009  Verbal Abuse Physical Abuse  Health & Safety Code 

  $800.00

 

Name at time: Mayers Memorial Hospital D/P SNF
The facility was cited for failing to report an incident of suspected abuse to The Department within 24 hours. The incident happened on 9/27/09, and was not reported for four days. Citation # 230006640.

09/22/2009  Dignity Verbal Abuse  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 7/31/09, a staff member recorded a resident's name and the statement, "quit j..king off" onto a recording device and then repeatedly played it loudly at the nursing station. The perpetrator stated she made and played the recording as a joke because the resident had a history of masturbation. She reported she acted willfully and didn't think about dignity and respect. The resident was 78-years-old and suffered from dementia and depression. A staff member who witnessed the incident reported that, "I thought it was demeaning to him," and "It's not nice to make fun of him." The derogatory and demeaning statements violated the resident's right to be treated with dignity and respect. Citation # 230006554.

09/22/2009  Mandated Reporting  Health & Safety 

  $700.00

 

Name at time: Mayers Memorial Hospital D/P SNF
The facility failed to immediately report suspected abuse of a resident that took place on 7/31/09. It did not report the abuse of a 78-year-old resident with dementia until 8/27/09, 27 days later. It was cited for failing to report the abuse to The Department within 24 hours. Citation # 230006553.

04/17/2009  Deterioration  Required Services 

  $15,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 12/24/08, a 23-year-old resident complained of chest pain around 12:45 pm. At 3 pm, a chest x-ray and EKG were ordered and completed by the physician. At 3:30 pm, the resident was found by a staff person to be cyanotic and unresponsive to verbal and painful stimuli. The staff person failed to carry out a physician's order for CPR. At 4:30 pm, it was noted that the resident had no respiration or heart rate for one minute and passed away. The staff member who discovered the resident as cyanotic claimed she was so emotionally overwhelmed that all she could do was walk away. The facility was cited for failing to continuously assess and plan the care for a deterioration in the resident's condition and for failing to follow a physician's order to initiate CPR. Citation # 230006089.

12/30/2008  Physical Abuse  Patient Rights 

  $800.00

 

Name at time: Mayers Memorial Hospital D/P SNF
During an interview, a staff member indicated that between 8/31/08 and 11/20/08, a resident grabbed another resident's shoulder and forced her into her wheelchair, hit her several times, and cursed at her. On 12/7/08, the resident was seen wheeling the other resident into his room. When she did not want to go into the room, he forced her. The residents are a married couple, but live in separate rooms due to the husband's aggression. The facility was cited for failing to protect the resident from physical abuse. Citation # 230005735.

12/11/2008  Mandated Reporting Verbal Abuse  Failure to Report 

  $800.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 10/23/08, a staff member witnessed a resident being verbally abused by another staff member. The incident was not reported to the Department until 10/27/08, four days after the alleged incident. The facility was cited for failing to report incidents of suspected or known abuse within 24 hours to the Department as stated on the facility's policy and procedure. Citation # 230005678.

10/18/2007  Verbal Abuse Mandated Reporting  Administration 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 7/4/07, a CNA overheard another CNA make inappropriate sexual remarks to a 94 year old female resident with Alzheimer's disease. The CNA waited two days to tell another CNA what she overheard, and that CNA waited until 7/19/07 (15 days after the original incident) to tell her charge nurse. The facility was cited for failing to report an alleged incident of verbal abuse to the Department of Health Services within 24 hours of the incident. Citation # 230004360.

10/18/2007  Sexual Abuse Verbal Abuse  Patient Rights 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 7/4/07, a CNA overheard another CNA making inappropriate sexual comments to a 94 year old female resident with Alzheimer's disease. He heard the CNA say to the resident, "Drink your milk. It's cum... You need to drink it because it took me all day to make it." He then overheard the CNA laugh. The facility was cited for failing to ensure the resident remain free from verbal, mental, sexual, or physical abuse. Citation # 230004356.

07/21/2004  Patient Rights  Patient Rights 

  $500.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 6/24/04, a 72-year-old female resident diagnosed with Alzheimer's, paranoid psychosis, and high blood pressure, pushed another female resident. On 6/27/04, the 72-year-old resident walked towards the other female resident and reached towards her. A visitor grabbed her arms and gave a quick tug, asking how she liked it. The facility was cited for failing to ensure that a resident was not subjected to physical abuse from a visitor. Citation # 230001086.

07/21/2004  Patient Rights  Patient Rights 

  $500.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 6/17/04 a staff member forced an 86 year old resident to take a shower against his will. The resident said that the staff person shoved him into a shower chair and kept him from leaving by holding her arm against him. A second staff person came upon the scene when she was attracted by the back and forth shouting between the resident and staff person in the shower room. The second staff member stated that the yelling was so intense that she couldn't get a word in to redirect. The facility was cited for failure to ensure that the resident was not subjected to physical or verbal abuse. Citation # 230001085.

09/25/2003  Careplan Fall  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
The careplan for a 74 year old resident at risk for falls called for a motion alarm to be set, so that staff would be alerted if the resident got up unassisted. On 6/19/03, the resident was found on the floor with a 1.5 centimeter laceration to her right temple area. The facility was cited for failing to implement the careplan by not applying the motion alarm. Citation # 230001059.

06/11/2002  Injury  Patient Care 

  $3,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
On 12/18/01, a 75-year resident was found on the floor of his room, impaled on a foot cradle that was used to keep the bed linen off of his foot ulcers. This resulted in a lacerated liver that required surgical repair and acute hospitalization. The resident had a history of falls and confusion, and staff later reported in interviews that the resident frequently dismantled and moved the foot cradle. The facility was cited for failing to recognize this as a hazard, and for failing to provide adequate supervision to prevent injury. Citation # 230000984.

03/24/2000  Medication Patient Records  Medication 

  $950.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Nine resident records were found to be illegible, incomplete and misfiled. After the reconstruction of the records, many treatments and medications were found to be incorrect. Facility cited for failure to follow physicians' orders and their own policy and procedures to dispense needs and treatments as prescribed for the nine residents Citation # 230000879.

03/24/2000  Patient Records Medication  Patient Records 

  $800.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Seven resident records were found to be illegible, incomplete and misfiled. After the reconstruction of the records, many treatments and medications were found to be incorrect. Facility cited for failure to follow physicians' orders and their own policy and procedures to dispense needs and treatments as prescribed for the seven residents Citation # 230000878.

04/22/1998  Decubiti (Bedsores)  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
A doctor ordered a special air mattress for a totally dependent resident and the staff was supposed to turn the resident every hour and report any signs of skin breakdown. The staff let the bed supplier take back the bed when the facility could no longer bill Medicare. The staff did not tell the physician about the bed or the ensuing skin breakdown. Citation # 230000789.

04/22/1998  Patient Care  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Facility allowed residents to sit in an areas that was in close proximity to the doorway of a resident with a history of violent behavior such as grabing other residents and throwing objects from her roomð -- Facility failed to ensure that other residents were protected from potential harm. Citation # 230000791.

02/25/1998  Fall  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Confused resident with history of falls had physician's orders for soft belt restraints while in her wheelchair and bed -- aide left resident unattended on toliet and she fell, cutting and bruising her left eye -- facility failed to provide adequate supervision to resident Citation # 230000773.

02/25/1998  Physical Abuse Supervision Injury  Patient Rights 

  $800.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Demented resident who wandered into other residents' rooms and pulled them from their beds late at night was not closely monitored -- she entered another resident's room after 2 a.m., poured water on the floor and took walker away from resident who was trying to get her to leave -- victim fell on the water, sustaining injuries which required treatment at emergency room -- facility failed to provide necessary supervision to prevent assaultive resident from interfering with other residents Citation # 230000774.

01/22/1998  Medication Decubiti (Bedsores)  Medication 

  $3,500.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Confused resident was given excessive dosages of antipsychotic drugs over a 12 week period -- his condition declined during that period with the development of five open pressure sores on his buttocks, testicles and heel, periods of lethargy from which he could not be aroused, possible pneumonia, and decreased ability to move and eat -- at no time did the pharmacist alert the administrator or director of nurses that resident was receiving excessive dosages even after being notified by a concerned nurse -- facility cited for failing to plan and assure that resident 's medication regimen was free from unnecessary drugs Citation # 230000760.

01/22/1998  Physical Abuse  Patient Rights 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Facility failed to prevent a resident, whose inappropriate behavior had occurred and been documented over several months, from abusing and harassing other residents, causing them to be abused and humiliated Citation # 230000767.

11/06/1997  Decubiti (Bedsores)  Patient Care 

  $750.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Staff noted resident's bedsore but did not inform physician for four days -- sore developed to Stage III -- facility failed to notify attending physician promptly of a marked adverse change in resident's skin Citation # 230000757.

10/01/1997  Patient Care Supervision  Patient Care 

  $1,000.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Physician ordered that when gravely ill resident was visited by a family member who exhibited bizarre behaviors (attempting to cover his head with a pillow, cutting the telephone cord in his room and perhaps trying to cut his intravenous line), resident was to be at the nurses' station -- his careplan was not changed and the family member was left alone in the room with the resident -- facility cited for failing to follow physician's order and failing to update resident's careplan which placed this resident in jeopardy of physical injury from a family member Citation # 230000742.

07/23/1996  Patient Rights Careplan  Patient Rights 

  $2,500.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Facility failed to review and revise careplan of excessively combative resident who struck other residents and visitors, was unrestrained even at night and known to enter other residents' rooms and hit them -- culminating in incident where he entered resident's room, struck her and was choking her when a nurse's aide entered the closed room to investigate the screams and he hit her -- facility cited for failing to prevent abuse, failing to develop and implement policies prohibiting mistreatment and abuse of residents and failing to revise abusive resident's careplan Citation # 230000683.

10/25/1994  Medication  Patient Care 

  $450.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Facility repeatedly gave psychotropic drugs to a resident without identifying behavior problems or monitoring behavior and side effects Citation # 230000589.

10/25/1994  Chemical Restraints  Medication 

  $900.00

 

Name at time: Mayers Memorial Hospital D/P SNF
Drugs were used in excess of limits for dose and duration -- used for facility convenience to control resident's behavior Citation # 230000591.

 

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