Inspection·June 24, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some osteoarthritis (Condition which can affect any joint in the body) and osteoporosis (condition in which bones become weak, and brittle). Her Minimum Data Set (MDS, an assessment tool), BIMS (Brief Interview for Mental Status) indicated a score of 15 (no cognitive impairment). During a concurrent interview, and record review on 6/20/22 at 3:03 p.m., with the Maintenance In Charge (MIC), he stated, No reports of temperature concerns reported since last week. Review of Maintenance Request Log indicated no outstanding work request in month of June 2022 related to room temperature. During an interview with Director Of Nursing on 6/20/22 at 3:30 p.m., she stated, Nursing staff should communicate with Engineer Department through Maintenance Request Form for temperature concerns in the facility. DON further stated, Staff from Engineer Department come and fix as needed, and they are on-call 24/7 for us. Resident 59 informed me about feeling cold today, our Engineer Department increased temperature by 2 points this afternoon. Review of facility policy titled, A/C and Heating System, dated 4/11/2017, indicated, The normal range of resident's room temperature is between 68 to 75 degrees for resident's comfort depend on the seasons and resident's preference without impacting other resident's comfort. It further indicated that when a resident complained about the temperature, engineer will be notified and adjustment will be made as appropriate. Furthermore, the above policy was not in alignment with Center for Medicaid, and Medicare Services, F584 regulation indicated, Comfortable and safe temperature levels, facilities must maintain a temperature range of 71 to 81 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 2 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 20 sampled residents (Residents 31 and 8). Failure to accurately assess the residents had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Residents Affected - Few Findings: 1. Review of Resident 31's Change of Condition Evaluation, dated 3/7/2022, indicated Resident 31 had an unwitnessed fall and was found sitting on the floor. Resident 31's MDS dated [DATE] was reviewed. Section J1800 asked the question, Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? The person who completed the MDS coded 0, which indicated Resident 31 did not have any falls during the specified time frame. During an interview and concurrent record review with the Minimum Data Set Nurse (MDSN) on 6/22/2022 at 11:15 a.m., the MDSN reviewed Resident 31's medical record and confirmed the resident fell on 3/7/2022. The MDSN stated this fall should have been coded on the MDS dated [DATE]. The MDSN reviewed Resident 31's 4/5/2022 MDS and confirmed the fall was not coded. The MDSN stated that instead of coding 0 in section J1800, the person who completed the MDS should have coded 1 to indicate Resident 31 fell during the specified time frame. Review of the Centers for Medicare & Medicaid Services (CMS) 10/2019 Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions) indicated for section J1800, Code 1, Yes if the resident had fallen during the specified time frame. 2. During an observation on 6/20/2022 at 10:57 a.m., Resident 8 was lying in bed. Resident 8 was observed raising her left hand pointing to her lower abdominal area, while her right arm was resting at the right side of her chest. During an interview with the certified nurse assistant C (CNA C) on 6/20/2022 at 11:00 a.m., CNA C stated Resident 8 was not using her right hand anymore. During an interview with restorative nurse aide D (RNA D) on 6/22/2022 at 9:55 a.m., RNA D confirmed Resident 8 had limitation to the right arm. During a concurrent interview and record review with the MDSN and the director of nursing (DON) on 6/22/2022 at 11:24 a.m., both MDSN and DON reviewed Resident 8's Quarterly MDS, dated [DATE]. Section G0400A which was about Functional Limitation in Range of Motion to Upper extremity was coded 0, which indicated there was no impairment on Resident 8's upper extremity. The quarterly MDS dated [DATE] and the annual MDS dated [DATE] were also reviewed. The MDSN and DON confirmed Section G0400A was coded 0 on both of these MDS assessments. The MDSN and the DON were not able to confirm the limitation on Resident 8's right upper extremity. During an interview with licensed vocational nurse G (LVN G) on 6/24/2022 at 8:33 a.m., LVN G confirmed Resident 8's right upper extremity had been weak and the resident was not able to use it ever (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 3 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0641 since she was admitted to the facility. Level of Harm - Minimal harm or potential for actual harm Review of the Centers for Medicare & Medicaid Services (CMS), Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), Version 1.17.1, dated 10/2019, indicated for Section G0400A, Code 1, impairment on one side: if resident has an upper extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 4 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of 20 sampled residents (Resident 14) when nursing staff did not apply Resident 14's left hand brace as ordered. This failure had the potential to affect the resident's care, health and well-being. Residents Affected - Few Findings: Review of Resident 14's clinical record indicated she was admitted on [DATE] and had the diagnoses of Alzheimer's disease (a condition characterized by memory loss), osteoarthritis (degenerative joint disease) of hand, and pain in left hand. Review of Resident 14's physician order, dated 8/25/20, indicated apply brace to left hand, ON in Am [morning] and OFF in PM [evening]. May remove during hygiene and activities of daily living (ADL) care. Check for skin redness or irritation every shift. Review of Resident 14's care plan for 'chronic pain' indicated, Interventions: apply brace to left hand, ON in Am and OFF in PM. During an observation on 6/22/22 at 1:00 p.m., while Resident 14 was sitting up in her wheelchair, there was no hand brace observed on her left hand. The hand brace was seen on top of Resident 14's bed. During a concurrent observation and interview on 6/22/22 at 1:25 p.m., registered nurse A (RN A) confirmed Resident 14 did not have the hand brace on her left hand. During a concurrent interview and record review on 6/22/22 at 1:28 p.m., RN A confirmed Resident 14 should have had the hand brace to her left hand. During an interview on 6/22/22 at 3:00 p.m., the DON stated nursing staff should have applied Resident 14's left hand brace as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 5 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three out of 12 sampled residents (Residents 5, 31, and 46) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 5 received lorazepam (brand name: Ativan; an anti-anxiety medication) without adequate indication for use, and without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) since April 2020 (more than 2 years ago); and trazodone (medication for depression) without a GDR since August 2018 (almost for 4 years ago); 2. Resident 31 received sertraline (brand name: Zoloft; medication for depression) since April 2021 without an attempted GDR; and 3. Resident 46 received sertraline since March 2019 (more than 3 years ago) without evidence of an attempted GDR. The failure resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include, but not limited to, sedation, blurred vision, falls, constipation, anxiety, agitation, confusion, and fatigue. Findings: The potential side effects related to anti-depressant medication use for which the facility monitored for residents receiving anti-depressants included: Nausea, headache, diarrhea/constipation, insomnia/somnolence, dizziness, nervousness, agitation, blurred vision, sedation, fatigue, confusion, and fatigue. 1. Resident 5 was an elderly resident admitted to the facility with diagnoses including psychotic disorder (condition characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions), major depressive disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and history of falling and fracture of the thighbone. A review of Resident 5's medical record indicated Resident 5 had been receiving: - Lorazepam (Ativan) 0.5 milligrams (mg, unit of measurement) twice daily related to anxiety disorder as evidenced by (aeb) #1 yelling out repetitive words, ex 'mar, mar', yelling out numbers and #2 constant restlessness, dated 4/3/2020; - Trazodone (an anti-depressant) 25 mg daily at bedtime related to insomnia since 8/30/2018. The medical record also indicated the resident had been on a high dose olanzapine (Zyprexa) 10 mg in the morning and 7.5 mg at bedtime (total 17.5 mg) for OTHER PSYCHOTIC DISORDER since 4/20/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 6 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 Level of Harm - Minimal harm or potential for actual harm Lexi-comp, a nationally recognized drug information resource, indicated the dosing ranged from 2.5 mg to maximum of 10 mg per day for agitation/aggression and psychosis associated with dementia in adults. There was no documented evidence in the medical record the facility attempted the GDRs for lorazepam since 4/30/2020 (more than 2 years ago); and for trazodone since 8/30/2018 (almost 4 years ago). Residents Affected - Few A review of the Consultant Pharmacist's (CP's) recommendation, signed by the physician on 10/21/21, indicated: Continue on the regimen of Zyprexa . Trazodone and Ativan. Benefits outweigh any potential side effects. These medications are at their lowest doses to maintain resident's baseline behaviors without side effects. Continued as ordered. On 6/21/22 at 11:51 a.m., Resident 5 was observed in a wheelchair in the dining room while she kept repeating baa baa baa maa maa constantly in a low to medium level voice. During an interview with Activity Staff A (AStaff A) on 6/21/22 at 11:55 a.m., she stated Resident 5 was normally calm and say ba ba ba constantly without physical or verbal aggressiveness. During an interview with Certified Nursing Assistant (CNA) H on 6/22/22 at 8:19 a.m., she stated Resident 5 could not talk or verbalize her needs; she used to have behaviors but I don't observe any with me. CNA H stated she thought the resident make song by saying baa baa baa often. During an interview with CNA I on 6/22/22 at 8:30 a.m., she stated Resident 5 had no behaviors, her speech is not fully comprehensible but she understands what we tell her. She goes baa baa waa waa often as if she sings but no aggressiveness. She stated the resident had a history of irritation when she was not fully awake and someone attempted to wake her. On 6/22/22 at 9:25 a.m., Resident 5 was observed lying in bed with CNA H beside her bed with the breakfast tray. The resident had her eyes closed and would not be awakened to eat breakfast. CNA H stated the resident slept a lot during the day. During an interview with CNA J on 6/22/22 at 9:32 a.m., she stated the resident sleeps a lot, when she's up, she's chiming or humming a song by going wa wa wa ba ba ba. She stated the resident could not talk or verbalize her needs, and had episodes of being angry. She stated, If she's angry, she grabs and digs her nails into your arm. CNA I stated Resident 5 had no anxiety or restlessness that she could observe. On 6/22/22 at 9:38 a.m., Resident 5 was observed in bed, eyes closed but saying baa baa baa baa constantly. On 6/22/22 at 10:07 a.m., Resident 5 was observed in bed being fed breakfast by CNA K. She stated the resident said Baa baa maa maa constantly . And that's all she does. Sometimes she plays with her food and gets upset when you try to stop her. CNA K stated the resident was confused and doesn't know what she's doing. When she gets upset, she will stop you and throws her food. CNA K stated the resident used to scratch when she did not want to be touched or bothered when staff were attempting to change her. CNA K added she was not aware of the resident exhibiting any anxiety or restlessness. On 6/22/22 at 10:34 a.m., Resident 5 was observed awake in her bed, saying baa baa baa constantly. There was no anxiety or restlessness observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 7 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 Level of Harm - Minimal harm or potential for actual harm On 6/22/22 at 11:12 a.m., Resident 5 was observed in the dining room, being calm while repeating baa baa baa in a medium level voice. During an interview with AStaff B on 6/22/22 at 11:14 a.m., she stated the resident called out baa baa baa all the time, and sometimes a bit loud during activity, but had no behaviors. Residents Affected - Few During an interview with the Social Service Designee (SSD) on 6/22/22 at 1:07 p.m., she stated the resident used to cuss at staff in her language a long time ago. She stated the resident had been calm for many months, and had no anxiety or restlessness. She confirmed the resident's calling out baa baa baa was not considered a behavior. During an interview with RN D on 6/22/22 at 2:59 p.m., she stated, Some days she's calm and other days she's agitated and aggressive. She says repetitive stuff . When she's agitated, she says baa baa baa. RN D said the staff monitored the calling out of baa baa baa as a behavior. During an interview with CNA L on 6/22/22 at 3:05 p.m., when asked if Resident 5 had any behaviors, CNA L responded, When she's up and singing in the chair by going baa baa baa baa. She confirmed that should not be considered a behavior. During an interview with RN E on 6/22/22 at 3:40 p.m., she stated Resident 5 used to have behaviors of scratching, hitting, and throwing stuff before but had been calm for many months. She stated the resident's singing baa baa baa is just her way of expressing herself and not a behavior. She added, That's not anxiety or restlessness. During a concurrent interview and record review with licensed vocation nurse (LVN) M on 6/23/22 at 8:11 a.m., she stated Resident 5 had been receiving lorazepam for calling out baa baa baa baa, and that the nursing staff had been monitoring that as a behavior. When asked how the calling out baa baa baa or numbers considered a behavior, LVN M stated, I'm not sure. She stated the resident had a history of anxiety by scudding down to the bottom of her wheel chair but that happened months or a year ago. During a concurrent interview and record review with the assistant director of nursing (ADON) on 6/23/22 at 8:45 a.m., she reviewed the medical record and stated the resident was receiving lorazepam for yelling out mar,mar and yelling out numbers. She said, Probably she was yelling out before. The ADON verified there had been no attempted GDRs for lorazepam since 4/3/20, and could not find any GDRs for trazodone since 2018. She acknowledged repetitive saying mar, mar was not indicative of anxiety or restlessness. During an interview with CNA N on 6/23/22 at 9:48 a.m., CNA N stated she had not observed Resident 5 being anxious or restless. She said, She's repetitive and maybe that's her way to communicate to calm herself as she cannot talk. A review of the Psychoactive Medication Summary (monthly summary of monitored behaviors)indicated the nursing staff had been monitoring for number of hour of sleep for trazodone use. The Summary indicated, from January 2021 to May 2022, the resident had been sleeping 6 to 14 hours per day. During another interview with the ADON on 6/23/22 at 10:40 a.m., she stated the resident had not been yelling but continued saying baa baa baa. She verified that should not be considered a behavior for medication use. She also confirmed there had been no attempted or failed GDRs for trazodone and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 8 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 lorazepam. Level of Harm - Minimal harm or potential for actual harm During a telephone interview with the CP on 6/23/22 at 10:45 a.m., she stated, We felt that we keep those [trazodone and lorazepam] and reduce the Zyprexa . Residents Affected - Few Resident 5's medical record indicated the Zyprexa was just reduced 2 months ago in April 2022 while the resident was receiving the same dose of trazodone since August 2018 and lorazepam since April 2020 without attempted GDRs. A review of the nursing progress notes, written on 6/24/22 at 11:10 a.m. by RN E, indicated, Called Dr. [Name] re: resident's behavior, no constant agitation, no yelling out, no restlessness, and sleeping 6-16 hours per day. Obtained new orders . 2. A review of Resident 31's medical record indicated she was an elderly resident admitted to the facility with diagnoses including dementia without behavioral disturbance, major depressive disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest), pain in right ankle and joints of the right foot, muscle weakness, abnormalities of gait and mobility, and history of multiple falls. During a concurrent observation and interview on 6/20/22 at 04:22 p.m., Resident 31 was observed awake and verbally responsive with some confusion. A review of Resident 31's medical record indicated a physician's orders: - Sertraline 100 mg (a moderate adult dose), give 1 tablet by mouth at bedtime for depression, dated 4/1/21; and - Monitor behavior of antidepressant medication use every shift. Behavior AEB #1: Verbalization of feeling depressed, and #2: Easily getting upset without any provocation; dated 1/6/22. A review of the Sertraline Psychoactive Medication Summary indicated the resident had the following number of episodes of #1 and #2 behaviors monthly: - January 2022: zero (0) episodes of either behavior - February 2022: 1 episode of each behavior - March 2022: zero episodes of #1 and 18 episodes of #2 - April 2022: 2 episodes of #1 and 6 episodes of #2 - May 2022: 3 episodes of each behavior - June 1- 23, 2022: zero episodes of either behavior. Resident 31's medical record indicated she was at a high risk for falls. The respective 2/9/21 and 4/6/21 Acknowledgement of High Risk for Fall documents indicated Resident's high risk for fall and most likely to have unwitnessed fall with potential injuries from fall while in SNF [skilled nursing facility . and Resident with history of multiple falls at home after resident discharge from SNF . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 9 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 respectively. Level of Harm - Minimal harm or potential for actual harm A review of Resident 31's medical record also indicated she had a unwitnessed fall on 3/7/22, and another fall on 6/10/22. Residents Affected - Few During another observation and interview on 6/24/22 at 8:53 a.m., Resident 31 was observed in bed, awake, pleasant, and verbally responsive. A review of Resident 31's medical record indicated there was no documented evidence the facility attempted a GDR for the sertraline since 4/1/21 (more than a year ago). A review the physician's progress notes, dated 7/12/21, indicated: [Resident 31] currently on Zoloft 100 mg po [by mouth] daily for Depression. Per direct care staff and IDT [interdisciplinary team] input, resident's behaviors are much improved and doing well with current dose. I agree with IDT recommendation to continue current dose to maintain resident's quality of life. Benefits far outweigh risks associated. Another physician's progress notes, dated 1/7/22, indicated: Resident has been taking Zoloft 100 mg po daily . Per direct care staff and IDT Behavioral Committee, resident's behaviors are much improved The benefits of continuing the current dose of Zoloft outweigh risks associated. Continue current dose of Zoloft. A concurrent interview and record review was conducted with the ADON and the DON on 6/24/22 at 9:40 a.m. They reviewed Resident 31's medical record, and stated there were documents of risk vs. benefit assessment from the physician (as mentioned above), but there had been no attempts of GDR for her sertraline since 4/1/21. They acknowledged the resident had very minimal target behaviors while she had several falls, and was at a high risk for more falls and other side effects due to dementia, advanced age, abnormalities of gait and mobility, pain, and concomitant use of other sedating medications. They verified the resident had no contraindication for a GDR. 3. A review of Resident 46's medical record indicated she was an elderly resident admitted to the facility with diagnoses including dementia with behavioral disturbance, MDD, general anxiety disorder, and difficulty in walking. On 6/22/22 at 2:25 p.m., 6/23/22 at 2:32 p.m., and 6/24/22 at 8:49 a.m., Resident 46 was observed sitting on a wheel chair, quiet, pleasant, and engaging in activities such as the bingo game or coloring. Resident 46's medical record indicated she had a physician's order, dated 3/15/19, for sertraline 100 mg, 1 tablet by mouth one time a day for depression/anxiety/agitation related to MDD. For sertraline use, the medical record indicated the staff monitored every shift for target behaviors #1: Crying; and #2: Verbalizing wanting to kill herself. Resident 46 also had the physician's order for: Zyprexa (an anti-psychotic medication) daily at various doses since December 2019. During an interview with CNA E on 6/23/22 at 2:34 p.m., he stated the resident sometimes wanted to go home and she would look for a family member. He stated he remembered hearing from another staff she had a history of verbalizing she wanted to kill herself, but that was a long time ago. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 10 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 Level of Harm - Minimal harm or potential for actual harm During an interview with CNA F on 6/23/22 at 2:40 p.m., she stated Resident 46 had occasional crying episodes when she missed her family. During an interview with RN B on 6/23/22 at 3:18 p.m., he stated the resident was mostly quiet and liked doing activities such as coloring. He stated, Once in a while she misses her daughter and then she cries. Residents Affected - Few During an interview with RN C on 6/24/22 at 9:30 a.m., she stated the resident had episodes of crying, and no more wanting to kill herself . that was long ago. A review of the Sertraline Psychoactive Medication Summary indicated Resident 46 had the following number of episodes for behaviors #1 (crying) and #2 (verbalizing wanted to kill herself): - June 2021: 1 episode of crying only - July 2021: 3 episodes of crying only - August 2021: 0 episodes of either behavior - September 2021: 0 episodes of either behavior - October 2021: 3 episodes of crying only - November 2021: 0 episodes - December 2021: 0 episodes - January 2022: 0 episodes - February 2022: 0 episodes - March 2022: 2 episodes of crying only - April 2022: 11 episodes of crying only - May 2022: 11 episodes of crying only - June 1- 23, 2022: zero episodes A review of Resident 46's medical record indicated there was no documented evidence the facility attempted a GDR for the sertraline since 3/15/19 (more than 3 years ago). A review of the CP's recommendations, dated 8/26/21 and 2/10/22, both indicated in pre-printed template: . Zoloft is also necessary to maintain depressive episodes at the minimum. The benefits outweigh the risks. Continue as order. The hand-written rationale by the physician, dated 2/14/22, indicated, The benefits outweigh the risks. Continue as ordered. During a concurrent interview and record review with the ADON and DON on 6/24/22 at 10:18 a.m., they confirmed there were documented benefit risk/benefit assessment (as mentioned above) but there had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 11 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been no attempted GDRs for the sertraline since March 2019 despite minimal episodes of crying. They both acknowledged Resident 46 was at a high risk for falls and other side effects due to advanced age, dementia, difficulty walking, and concomitant use of sedating medications such as Zyprexa. A review of the facility's provided policy and procedures titled Medication Management, dated 1/2020, indicated: Within the first year in which a resident is admitted on a psychotropic medication ., the facility must attempt a GDR in two separate quarters . After the first year, a GDR must be attempted annually, unless clinically contraindicated For any individual who is receiving a psychotropic medication to treat expressions . the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: - The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and [word and bolded and underlined] - The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 12 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility document review, the facility failed to ensure food served was palatable and attractive. These deficient practices had the potential to impact the residents' nutritional status and not meet the residents' desire to be served food they felt was palatable and attractive. Residents Affected - Few Findings: During an interview with Resident 60 on 6/20/2022 at 10:42 a.m., Resident 60 stated the food in the facility had no seasoning. Review of the facility menu for 6/21/2022 lunch indicated chicken parmesan breast, parslied fettuccini, seasoned cauliflower, garlic breadstick, and fruit cocktail with whipped topping. A test tray of regular and dysphagia 1 (pureed) diet was conducted on 6/21/2022 at 12:45 p.m. During the test tray, in the presence of certified dietary manager B (CDM B), the regular chicken and the regular/dysphagia 1 broccoli (replaced cauliflower) tasted bland. The regular broccoli appeared pale, overcooked and the texture was mushy. CDM B agreed the regular chicken and the regular/dysphagia 1 broccoli tasted bland. CDM B agreed the regular broccoli was overcooked and the texture was mushy. Review of the facility policy and procedure Performance Improvement Resident Satisfaction reviewed 2/2021, indicated The food and nutrition services department makes the maximum effort to ensure the appetizing appearance, palatability, appropriate serving temperatures, and nutrient retention of food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 13 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: Residents Affected - Some 1. Pans were stacked and stored wet; 2. There were undated, unlabeled, and outdated food items in the reach-in refrigerator and dry storage area; and 3. Colanders were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 83 of 85 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 6/20/22 at 9:10 a.m., with [NAME] 1 (Cook 1) six metal pans of various sizes were observed stacked on the counter next to the stove. The pans were upright and stacked inside of one another. All of six pans were wet on the inside and outside surfaces of the metal containers. [NAME] 1 stated he had washed the metal pans after breakfast in the three-compartment sink. [NAME] 1 confirmed the pans were wet and he stated the pans should not be stacked and stored wet and should be air-dried. Review of the facility's Food Service and Nutrition Department procedure titled Three-sink Washing, revised 4/2013 and reviewed 2/2022, indicated to clean the pots and pans using the three-sink method. When the pans are clean, turn them upside down to air dry. Store them on the counter upside down. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored. 2. During the initial kitchen tour on 6/20/22 at 9:30 a.m., with the registered dietician (RD), the following were observed in the dry storage area of the kitchen: one bag of sliced almonds labeled with a discard date of 6/9/22 and 24 undated English muffins. The RD confirmed the observations and stated the nuts should have been discarded by 6/9/22. The RD further stated the English muffins should have a facility sticker indicating the date the muffins were received and a use by date. The RD confirmed the English muffins were undated and should be discarded. During the initial kitchen tour on 6/20/22 at 9:30 a.m., with the RD, the following were observed in the reach-in refrigerator: a container of chicken soup with a discard date of 6/19/22, a package of sliced chicken with a discard date of 6/19/22, and a container of watermelon with a discard date of 6/19/22. Four individual salads in plastic containers, a cup of watermelon, and a cup of pineapple were on a plastic tray in the reach-in refrigerator. The individual items and the tray were not dated. The RD confirmed the observations and stated the items on the tray should be dated when they are prepared and refrigerated. The RD further stated the items with the discard date of 6/19/22 should have been removed from the reach-in refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 14 of 15 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 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 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 0812 Level of Harm - Minimal harm or potential for actual harm Review of the facility's Food Service and Nutrition Department procedure titled Label & Dating Guidelines revised 2/2022, indicated to ensure proper food safety and quality all employees will follow guidelines when storing, labeling, and dating foods. Once product is opened, will label with date food must be discarded . Bread bags must be tied and labeled and dated . food that is prepared and not served shall be stored appropriately, clearly labeled and dated . No food is to be kept longer than the expiration date. Residents Affected - Some 3. During an observation and interview with certified dietary manager B (CDM B) on 6/21/22 at 2:30 p.m. in the kitchen, three metal colanders of various sizes were observed stacked on the shelf next to the sanitizing sink. The colanders were right-side up and stacked inside of one another. All three colanders were wet on the inside and outside surfaces of the metal containers. CDM B confirmed the colanders were wet. CDM B stated the colanders should have been air dried before being stacked and stored. During an observation and interview with CDM B on 6/23/22 at 10:16 a.m. in the kitchen, four metal colanders of various sizes were observed stored on the shelf next to the sanitizing sink. All four colanders were right-side up and stacked inside of one another. CDM B confirmed the colanders were right-side up. CDM B stated the colanders should be stored upside down. Review of the facility's policy and procedure Management of the Environment of Care Dishes and Silverware reviewed 2/2022, indicated Turn them upside down to air dry. Store them on the counter upside down. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 15 of 15