Inspection·October 25, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the minimum requirement to provide 3.5 Direct Care Service Hours Per Patient Day (DHPPD, it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census) for eight days for the month of August to meet the resident's needs for one of two residents (Residents 1). This failure had the potential to affect Resident 1 and other residents ' care and wellbeing. Findings: 1. A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including type 2 diabetes (DM, high blood sugar), hemiplegia and hemiparesis (one-sided weakness and paralysis), and depression (a mood disorder that interferes with daily life). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/02/23, the MDS indicated he had a brief interview of mental status (BIMS, a structured cognitive test) score of 15 (cognitively intact). During a review of the facility's shower schedule, the schedule indicated that his shower days were Mondays and Thursdays. During a review of Resident 1's care plan for ADL, the care plan indicated Resident 1 requires extensive to total assistance by one staff with bathing/showering 2X/week and, as necessary, was initiated on 8/25/23. During a review of Resident 1's Activities of Daily Living (ADL) task for bathing, the task indicated that he took a shower on 8/24/23 (Thursday) and 8/31/23 (Thursday), but not 8/28/23 (Monday). During a document review titled Census and Nursing Hours Per Patient Day in August 2023, it was indicated that the following dates with actual DHPPD were below 3.5: 8/05-3.27; 8/06-3/16; 8/12-3.49; 8/19-3.49; 8/20-3.47; 8/26-3.25; 8/27-2.99; and 8/28-3.37. During an interview and DHPPD review on 9/01/23 at 11:30 a.m. with the Executive Leader (EL), she confirmed the above record review. During an interview and facility document review on 9/01/23 at 11:40 a.m. with the Administrative Assistant (AA), she stated they were understaffed in August. The AA acknowledged that the Direct Care Service Hours Per Patient Day (DHPPD) should have been at least 3.5. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055462 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 10/25/2023 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)