Inspection·March 19, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hearing, feeling or believing things that others do not, feeling unusually suspicious or having muddled thoughts, feeling agitated or hyperactive, very excited, elated, or impulsive ) 5 milligrams (mg, unit of dose measurement) one tablet by mouth two times a day to vascular dementia with behavioral disturbance. During an interview with the Minimum Date Set Coordinator (MDSC) on 3/19/24 at 11:01 a.m., The MDSC stated she was responsible for the PASRR program and confirmed that no documentation indicated Resident 6's Level 2 evaluation was completed until 3/18/2024. The MDSC further stated that Resident 6's PASRR level one evaluation was positive in June 2022 and she should have received a PASRR level two evaluation at that time. 2. A review of Resident 35's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia with behavioral disturbance, and schizophrenia. A review of Resident 35's physician order indicated that Resident 35 received Seroquel tablet 25 mg by mouth two times a day related to schizophrenia on 3/31/2023. During an interview with the MDSC on 3/19/24 at 11:05 a.m., The MDSC confirmed that no documentation indicated that Resident 35's Level 2 evaluation was completed until 3/18/2024. The MDSC stated that MDS staff should have referred Resident 35 for a level 2 PASRR evaluation after she was diagnosed with schizophrenia to ensure Resident 35 could receive appropriate care and services. During an interview with the Director of Nursing (DON) on 3/19/24 at 12:57 p.m., The DON confirmed that no documentation indicated that PASRR Level 2 evaluations were completed for residents 6 and 35 until 3/18/2024. The DON further stated that the MDS staff should have referred those two residents for PASRR 2 evaluation to ensure they could receive proper treatment and care. A review of the facility's undated policy, titled PASRR General Overview, indicated, The PASRR process is divided into two components . the RR process is completed for current NF residents, readmission, or inter-facility transfers when there is a significant change in the individual's physical or mental condition . A level 1 screening is used to identify if an individual has, or is suspected of having a PASRR condition, then a Level 2 Evaluation will be performed, and a determination made . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 2 of 31 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 03/19/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement, comprehensive, resident-centered, care plans for five out of twenty sampled residents, (Residents 51, 42, 47, 43 and 82), when the activity care plans of Residents 51, 42, 47, 43 and 82, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 51's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses including unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), unspecified chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). During an observation of Resident 51 on 3/11/24 at 9:40 a.m., Resident 51 was sitting in her wheelchair, alert, calm and verbally responsive. Review of Resident 51's active physician orders as of 3/12/24 indicated, Resident 51 may participate in activities as desired, ordered on 1/21/19. During the interview with the activity director (AD), on 3/13/24 at 2:21 p.m., AD stated that they do room visits three times per week and had her nails and hair done. AD further stated that Resident 51 also had communions in her room, twice per month. Review of Resident 51's care plans indicated, Resident 51 did have one on one room visits three times per week in the interventions of her activity care plan but there were no specific activities to be provided during the room visits and this intervention was not updated since it was created on 1/25/19. Resident 51's activity care plan, was not comprehensive and resident-centered, that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 51's activity care plan and interview with the quality assurance registered nurse (QARN), on 3/15/24 at 9:14 a.m., QARN verified, Resident 51 did not have specific activities to be provided during the room visits, and the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/19. QARN further verified, Resident 51's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. QARN stated she would notify the AD to update this intervention in the activity care plan of Resident 51. During an interview with AD, on 3/15/24 at 11:45 a.m., AD verified, Resident 51 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/19. AD further verified, Resident 51's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 3 of 31 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 03/19/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 51 should have a comprehensive, resident-centered activity care plan; and that, she will update Resident 51's activity care plan. 2. Review of Resident 42's face sheet indicated, Resident 42 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (adult onset and most common type of diabetes which is a condition that occurs when the blood glucose is too high), unspecified hyperlipidemia (a condition in which there are high levels of fat particles in the blood) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). During an observation of Resident 42 on 3/11/24 at 11:35 a.m., Resident 42 was lying in bed in his room, alert, calm and comfortable. Review of Resident 42's activity initial assessment on 3/11/22 indicated, Resident 42 likes to watch television shows, listen to country and western music, playing solitaire (card game) and going out into the garden. During the interview with the activity director (AD), on 3/13/24 at 2:24 p.m., AD stated that they do room visits three times per week, socializing with Resident 42, playing music and watching movies. AD further stated that Resident 42 also wanted to play with the iPad [brand name of a touchscreen tablet computer]. Review of Resident 42's care plans indicated, Resident 42 did have one-on-one room visits three times per week in the interventions of his activity care plan but there were no specific activities to be provided during the room visits; and that, this intervention was not updated since it was created on 3/8/22. Resident 42's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. During a concurrent record review of Resident 42's activity care plan and interview with the QARN, on 3/15/24 at 9:16 a.m., QARN verified, Resident 42 did not have specific activities to be provided during the room visits; and that, the one-on-one room visit activity care plan intervention was not updated since it was created on 3/8/22. QARN further verified, Resident 42's activity care plan was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The QARN stated she would notify the AD to update this intervention in the activity care plan of Resident 42. During an interview with AD, on 3/15/24 at 11:47 a.m., AD verified, Resident 42 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 3/8/22. AD further verified, Resident 42's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 42 should have comprehensive, resident-centered activity care plan and she will update Resident 42's activity care plan. 3. Review of Resident 47's face sheet indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), unspecified severe protein-calorie malnutrition (refers to a nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 4 of 31 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 03/19/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some status in which reduced availability of nutrients leads to changes in body composition and function characterized by obvious significant muscle wasting, loss of subcutaneous fat or significantly reduced functional capacity) and unspecified atrial fibrillation. During an observation of Resident 47 on 3/11/24 at 11:55 a.m., Resident 47 was lying in bed in his room, alert, calm, and comfortable. Review of Resident 47's active physician orders indicated, Resident 51 may participate in activities as desired, ordered on 1/25/23. During the interview with the activity director (AD), on 3/13/24 at 2:08 p.m., AD stated that they do one on one room visits twice per day, socializing with Resident 47, watching Netflix (streaming service that offers a wide variety of shows) channels and doing sensory stimulation. Review of Resident 47's care plans indicated, Resident 47 did have one-on-one room visits but just three times per week in the interventions of his activity care plan and there were no specific activities to be provided during the room visits and this intervention was not updated since it was created on 1/25/23. Resident 47's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 47's activity care plan and interview with the QARN, on 3/15/24 at 9:08 a.m., QARN verified, Resident 47 did not have the right frequency of the one-on-one room visits; there were no specific activities to be provided during the room visits; and, the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/23. QARN further verified Resident 47's activity care plan was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and would notify the AD to update this intervention in the activity care plan of Resident 47. During an interview with AD, on 3/15/24 at 11:40 a.m., AD verified, Resident 47 did not have the right frequency of one-on-one room visits; there were no specific activities to be provided during the room visits; and, the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/23. AD further verified Resident 47's activity care plan was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. AD then stated that Resident 47 should have a comprehensive, resident-centered activity care plan; and that, she will update Resident 47's activity care plan. 4. Review of Resident 43's face sheet indicated, Resident 43 was admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), unspecified hyperlipidemia and unspecified acute kidney failure (a condition in which the kidneys suddenly could not filter waste from the blood). During an observation of Resident 43 on 3/11/24 at 12:02 p.m., Resident 43 was lying in bed in his room, confused and could not talk. Review of Resident 43's active physician orders as of 3/12/24 indicated, Resident 43 may participate in activities as desired, ordered on 8/24/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 5 of 31 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 03/19/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the interview with the activity director (AD), on 3/13/24 at 2:08 p.m., the AD stated that they do one-on-one room visits three times per week, socializing with Resident 43 and reading the bible. Review of Resident 43's care plans indicated, Resident 43 did have one-on-one room visits three times per week in the interventions of his activity care plan, but there were no specific activities to be provided during the room visits and this intervention was not updated since it was created on 8/24/22. Resident 43's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 43's activity care plan and interview with the QARN, on 3/15/24 at 9:11 a.m., the QARN verified, Resident 43 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 8/24/22. QARN further verified, Resident 43's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The QARN stated she would notify the AD to update this intervention in the activity care plan of Resident 43. During an interview with AD, on 3/15/24 at 11:42 a.m., the AD verified Resident 43 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 8/24/22. AD further verified, Resident 43's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 43 should have a comprehensive, resident-centered activity care plan. She stated she would update Resident 43's activity care plan. 5. Review of Resident 82's face sheet indicated, Resident 82 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, unspecified hyperlipidemia and unspecified hyperglycemia (high blood glucose or high blood sugar). During an observation of Resident 82 on 3/11/24 at 12:15 p.m., Resident 82 was sitting in the wheelchair in his room, alert, oriented, and comfortable. Review of Resident 82's active physician orders as of 3/12/24 indicated, Resident 82 may participate in activities as desired, ordered on 6/29/23. During the interview with the activity director (AD), on 3/13/24 at 2:28 p.m., AD stated that Resident 82 had no room visits because he goes out to the activity room and participates in the activities. Resident 82 does socialization, exercise, morning coffee, watching television and reading. Review of Resident 82's care plans indicated, Resident 82 had one-on-one room visits three times per week in the interventions of his activity care plan, and this intervention was not updated since it was created on 6/29/23. Resident 82's activity care plan, was not followed and it was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 6 of 31 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 03/19/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent record review of Resident 82's activity care plan and interview with the QARN, on 3/15/24 at 9:18 a.m., QARN verified, Resident 82's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. QARN further verified that the one-on-one room visit intervention in the activity care plan of Resident 82 was not followed or updated and would notify the AD to update the activity care plan of Resident 82. During an interview with AD, on 3/15/24 at 11:49 a.m., AD verified, Resident 82's activity care plan, was not followed. AD further verified that Resident 82's activity care plan was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. AD then stated that Resident 82 should have a comprehensive, resident-centered activity care plan; and that, she will update Resident 82's activity care plan. During an interview with the director of nursing (DON), on 3/19/24 at 11:25 a.m., DON verified that residents should have comprehensive and resident-centered activity care plans that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs; and that, the activity care plans of the above residents should be updated. Review of the facility's policy and procedure titled, Care Plan - How to Write, effective 1/7/2006, and reviewed 10/2010, indicated, Each resident upon admission and change of condition will have an individualized written care plan to reflect his/her healthcare and nursing needs. The plan will be developed with resident, family, significant other, licensed nurse, physician and interdisciplinary team (IDT, group of professionals from varioushealthcare disciplinhes that brings together knowledge to help people receive the care they need) . Each nursing diagnosis recorded on the care plan must have resident centered expected outcomes (goals, objectives) and dates, including resolution dates - all outcomes should be specific and measurable to the individual resident . Determine nursing interventions for the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 7 of 31 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 03/19/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 document care consistent with professional standards of practice, to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) from possibly getting worse for one out of six residents (Resident 238) investigated with pressure ulcer, when staff did not document whether they turned and repositioned Resident 238 every two hours, from 6/23/23 to 6/27/23. This failure resulted in the lack of documentation for whether Resident 238 was turned and repositioned. Residents Affected - Few Findings: Review of Resident 238's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 238 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture (bone is broken but the skin is intact) with routine healing, unspecified heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and unspecified Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 238's admission skin pressure ulcer assessment (comprehensive evaluation) dated 6/23/23, indicated, Resident 238 had suspected deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues), sacral (located below the lumbar spine and above the tailbone) coccygeal (at the very bottom of the spine, also known as the tailbone) pressure ulcer measuring 8 centimeters (cm, unit of length) x 9 cm, with the center of the wound covered with a layer of glossy/shiny drainage surrounded by non-blanchable (discoloration of the skin that does not turn white when pressed) redness, which was a suspected deep tissue injury, measuring, 2 cm x 0.7 cm x 0.1 cm. Resident 238 to be turned and repositioned routinely. Review of Resident 238's skin pressure ulcer assessment dated [DATE], indicated, there were no changes in Resident 238's pressure ulcer. Review of Resident 238's care plan for her pressure ulcer indicated, turning and repositioning of Resident 238 every 2 hours and as needed in bed in the interventions, revised on 8/22/23. Review of Resident 238's turning and repositioning program task documentation for certified nursing assistants, indicated that it was initiated at 12:00 p.m., on 6/28/23. During an interview with quality assurance registered nurse (QARN) on 3/19/24 at 10:00 a.m., QARN verified that the task of turning and repositioning of Resident 238 every 2 hours was initiated on 6/28/23 and not on admission to the facility, which was 6/23/23. During an interview with the director of nursing (DON) on 3/19/24 at 11:08 a.m., DON verified that the task for the certified nursing assistants to turn and reposition Resident 238 every 2 hours was started on 6/28/23, and not on 6/23/23. DON further verified that there was no documentation to indicate Resident 238 was turned and repositioned every 2 hours, from 6/23/23 to 6/27/23. The certified nursing assistants started to document the task of turning and repositioning every 2 hours on 6/28/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 8 of 31 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 03/19/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the undated facility's policy and procedure titled, Skin Care and Wound Management, indicated, All residents are considered at risk for pressure ulcer/injury development. All residents have preventative measures in place that include pressure redistribution mattresses on all beds, wheelchair cushion, heel boots or suspension, frequent repositioning per certified nursing assistant (CNA) and activities of daily living (ADL, personal care related activities) care, incontinent care provided with skin cleansers/wipes and barrier cream application if needed. Event ID: Facility ID: 055462 If continuation sheet Page 9 of 31 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 03/19/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow physician's orders for oxygen (a component of air essential to living organisms) rate administration for 1 of 3 sampled resident (Resident 48). This failure had the potential to compromise Resident 48's health and well-being. Residents Affected - Few Findings: Review of Resident 48's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 48 readmitted to facility on 3/6/2023. Review of Resident's admission diagnoses including systemic inflammatory response syndrome (a condition in which there is inflammation [a normal part of the body's response to injury or infection] throughout the whole body), anemia (a condition in which the body does not have enough healthy red blood cells to provide oxygen to body tissues), and chronic kidney disease (a gradual loss of kidney function over the time). Review of Resident 148's physician orders ,dated 3/7/2024, indicated, Oxygen at 2 LPM (LPM: liters per minute, oxygen measured in liters per minute) via nasal cannula (NC, a medical device to provide supplemental oxygen to residents) continuously for SOB (shortness of breath - difficulty in breathing)/anemia. During an observation on 3/11/2024 at 2:36 p.m., Resident 48's room air concentrator's (RAC, a medical device that takes in air from the room and filters out nitrogen (a component of air) to provides higher amounts of oxygen) oxygen rate was set at 2.5 LPM, which was delivered via NC for Resident 48. During a second observation on 3/12/2024 at 9:39 a.m., Resident 48's RAC's oxygen rate was set at 2.5 LPM via NC. During a concurrent review of Resident 48's physician orders for oxygen rate and an interview with registered nurse I (RN I) on 3/1/2024 at 9:44 a.m., RN I confirmed Resident 48's RAC was set to deliver oxygen at a rate of 2.5 LPM. RN I confirmed Resident 48 had an order for oxygen rate for 2 LPM. RN I adjusted RAC's oxygen rate to 2 LPM and stated staff should have verified and followed the physician order for oxygen rate for Resident 48. RN I stated staff should have set oxygen rate at 2 LPM, and not at 2.5 LPM for Resident 48 as ordered. During an interview with director of nursing (DON) on 3/15/2024 at 11:21 a.m., the DON stated staff should have set RAC at rate of 2 LPM for Resident 48. Review of facility's policy and procedure (P&P) titled, Oxygen Therapy-Nasal Cannula and Simple Mask, effective 01/08, indicated, Set the flowmeter to the setting ordered by the physician. Turn on the oxygen at the flow rate as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 10 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 3/11/24 at 11:27 AM, Resident 69 was observed in bed, with the two upper siderails in the raised position. Review of Resident 69's face sheet indicated Resident 69 admitted to the facility on [DATE]. Review of Resident 69's physician order, dated 4/19/23, indicated Resident 69 had an order for bilateral (both sides) upper side rails to be up when in bed for bed mobility. A review of Resident 69's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:20 AM, Resident 16 was seen lying in bed, with the two upper siderails and two lower siderails in the raised position. Review of Resident 16's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 16's physician order, dated 7/4/23, indicated Resident 16 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 16's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:33 AM, Resident 388 was observed in the room sitting in wheelchair next to the bed. Two upper siderails were in the raised position for Resident 388's bed. Review of Resident 388's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 388's physician order, dated 3/1/24, indicated Resident 388 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 388's clinical records indicated no documentation that the facility attempted alternatives or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:33 AM, Resident 389's bed was observed with two upper siderails were in the raised position. Review of Resident 389's face sheet indicated he was admitted to the facility on [DATE]. Review of Resident 389's physician order, dated 3/1/24, indicated Resident 388 had an order for bilateral upper side rails to be up when in bed for bed mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 11 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm A review of Resident 389's clinical records indicated no documentation that the facility attempted alternatives or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:38 AM, Resident 83's bed with two upper siderails were in the raised position. Residents Affected - Many Review of Resident 83's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 83's physician order, dated 2/21/24, indicated Resident 83 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 83's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:40 AM, Resident 28's bed was observed with two upper side rails in the raised position. Review of Resident 28's face sheet indicated she was admitted to the facility on [DATE]. Review of Resident 28's physician order, dated 2/23/24, indicated Resident 28 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 28's clinical records indicated no documentation that the facility attempted alternatives or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/12/24 at 10:08 AM, Resident 59 was seen in bed, with the two upper siderails in the raised position. Review of Resident 59's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 59's physician order, dated 3/16/23, indicated Resident 59 had an order for bilateral (both sides) upper side rails to be up when in bed for bed mobility. A review of Resident 59's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:02 AM, Resident 77's bed with two upper siderails were in the raised position. Review of Resident 77's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 77's physician order, dated 1/26/24, indicated Resident 77 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 77's clinical records indicated no documentation that the facility attempted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 12 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:03 AM, Resident 58's bed with two upper siderails were in the raised position. Residents Affected - Many Review of Resident 58's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 58's physician order, dated 3/3/21, indicated Resident 58 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 58's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:57 AM, Resident 76's bed with two upper siderails were in the raised position. Review of Resident 76's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 76's physician order, dated 5/31/23, indicated Resident 76 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 76's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 10:43 AM, Resident 74's bed with two upper siderails were in the raised position. Review of Resident 74's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 74's physician order, dated 5/31/23, indicated Resident 74 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 74's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:11 AM, Resident 45's bed with two upper siderails were up. Review of Resident 45's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 45's physician order, dated 4/22/21, indicated Resident 45 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 45's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 13 of 31 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 03/19/2024 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 0700 During an observation on 3/11/24 at 11:11 AM, resident 387's bed with two upper siderails were up. Level of Harm - Minimal harm or potential for actual harm Review of Resident 387's face sheet indicated they were admitted to the facility on [DATE]. Residents Affected - Many Review of Resident 387's physician order, dated 3/4/24, indicated Resident 387 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 387's clinical records indicated no documentation that the facility attempted alternatives or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:14 AM, Resident 34's bed with two upper siderails were in the raised position. Review of Resident 34's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 34's physician order, dated 5/10/23, indicated Resident 34 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 34's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:14 AM, Resident 4's bed with two upper siderails were up. Review of Resident 4's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 4's physician order, dated 11/17/23, indicated Resident 4 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 4's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:23 AM, Resident 68's bed with two upper siderails were in the raised position. Review of Resident 68's face sheet indicated Resident 68 admitted to the facility on [DATE]. Review of Resident 68's physician order, dated 4/2/22, indicated Resident 68 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 68's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:23 AM, Resident 2's bed with two upper siderails were up. Review of Resident 2's face sheet indicated Resident 2 admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 14 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident 2's physician order, dated 1/6/23, indicated Resident 2 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 2's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 11:45 AM, Resident 50's bed with the left upper siderail was in the raised position. Review of Resident 50's face sheet indicated Resident 50 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia with agitation (disorder of the brain) Review of Resident 50's physician order, dated 4/11/23, indicated Resident 50 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 50's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 12:35 PM, Resident 390's bed with two upper siderails were in the raised position. Review of Resident 390's face sheet indicated Resident 390 admitted to the facility on [DATE]. Review of Resident 390's record indicated no physician order for the use of siderails. A review of Resident 390's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 12:35 PM, Resident 18's bed with two upper siderails were up. Review of Resident 18's face sheet indicated Resident 18 admitted to the facility on [DATE]. Review of Resident 18's physician order, dated 1/29/24, indicated Resident 18 had an order for bilateral upper side rails to be up when in bed for bed mobility. A review of Resident 18's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/11/24 at 12:42 PM, Resident 26's bed with two upper side rails were in the raised position. Review of Resident 26's face sheet indicated they were admitted to the facility on [DATE]. Review of Resident 26's physician order, dated 9/17/19, indicated Resident 26 had an order for bilateral upper side rails to be up when in bed for bed mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 15 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of Resident 26's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an interview with the Director of Nursing (DON) on 3/15/24 at 11:15 a.m., DON confirmed there were no informed consent taken prior to use of side rails, no documentation for explained risk and benefits of side rails, and no attempts for alternatives for side rails for Resident 69, 16, 388, 389, 83, 28, 59, 77, 58, 76, 74, 45, 387, 34, 4, 68, 2, 50, 390, 18, and 26. During an interview with LVN G on 3/15/24 at 1:42 p.m., LVN G confirmed there was no assessment for entrapment related to the use of siderails, and alternatives tried before started suing side rails for all above residents. LVN G stated all above resident's bed had the siderails in the raised position. During an interview with CNA H on 3/15/24 at 1:47 pm., CNA H confirmed all above resident's beds had the siderails in the raised position. During an initial tour observation on 3/11/2024 at 10:26 a.m., resident 27's bed's both upper side rails were up. Review of Resident 27's face sheet indicated Resident 27 was admitted to facility on 5/5/2015 and readmitted on [DATE]. Review of Resident 27's physician's order, dated 5/17/2027, indicated Resident 27 had an order for upper half rails up when in bed for bed mobility. A review of Resident 27's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent (process of communication between resident and facility for agreement or permission to use side rails for bed) for use of side rails or assessed for risk of entrapment (being caught in) prior to using the bedside rails upon admission to facility. During an initial tour on 3/11/2024 at 10:30 a.m., observed Resident 54's bed's both upper side rails were up while Resident 54 was in bed. Review of Resident 54's face sheet indicated Resident 54 admitted to facility on 8/2/2023. Review of Resident 54's physician order, dated 8/10/23, indicated Resident 54 had an order for upper half rails up when in bed for bed mobility. A review of Resident 54's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:02 a.m., Resident 25's bed had both upper side rails up. Review of Resident 25's face sheet indicated Resident 25 admitted to facility on 1/29/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 16 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident 25's physician order, dated 1/29/22, indicated Resident 25 had an order for upper half rails up when in bed for bed mobility. A review of Resident 25's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:02 a.m., Resident 49's bed was with both upper side rails up while Resident 49 was not in bed. Review of Resident 49's face sheet indicated Resident 49 was initially admitted to facility on 5/14/2019 and readmitted on [DATE]. Review of Resident 49's physician order, dated 4/1/21, indicated Resident 54 had an order for upper half rails up when in bed for bed mobility. A review of Resident 49's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:15 a.m., Resident 78's bed was with both upper side rails up. Review of Resident 78's face sheet indicated Resident 78 admitted to facility on 2/9/2023. Review of Resident 78's physician order, dated 9/25/2023, indicated Resident 78 had an order for upper half rails up when in bed for bed mobility. A review of Resident 78's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:20 a.m., noted both upper side rails up for Resident 62's bed. Review of Resident 62's face sheet indicated Resident 62 admitted to facility on 2/9/2023. Review of Resident 62's physician order, dated 2/9/2023, indicated Resident 62 had an order for upper half rails up when in bed for bed mobility. A review of Resident 62's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:25 a.m., noted both upper side rails up for Resident 30's bed. Review of Resident 30's face sheet indicated Resident 30 initially admitted to facility on 10/10/2017 and readmitted to facility on 9/29/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 17 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident 30's physician order, dated 8/16/2022, indicated Resident 30 had an order for upper half rails up when in bed for bed mobility. A review of Resident 30's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:30 a.m., noted both upper side rails up for Resident 39's bed. Review of Resident 39's face sheet indicated Resident 39 initially admitted to facility on 10/28/2020 and readmitted to facility on 3/20/2023. Review of Resident 39's physician order, dated 3/20/2023, indicated Resident 39 had an order for upper half rails up when in bed for bed mobility. A review of Resident 39's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation and interview with resident 53 on 3/11/2024 at 11:45 a.m., noted both upper side rails up for Resident 53's bed. Review of Resident 53's face sheet indicated Resident 53 admitted to facility on 4/5/2022. Review of Resident 53's physician order, dated 4/5/2022, indicated Resident 53 had an order for upper half rails up when in bed for bed mobility. A review of Resident 53's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:00 p.m., noted both upper side rails up for Resident 15's bed. Review of Resident 15's face sheet indicated Resident 15 admitted to facility on 9/20/2023. Review of Resident 15's physician order, dated 9/20/2023, indicated Resident 15 had an order for upper half rails up when in bed for bed mobility. A review of Resident 15's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:15 p.m., noted both upper side rails up for Resident 79's bed. Review of Resident 79's face sheet indicated Resident 79 admitted to facility on 4/6/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 18 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident 79's physician order, dated 4/6/2023, indicated Resident 79 had an order for upper half rails up when in bed for bed mobility. A review of Resident 79's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:18 p.m., noted both upper side rails up for Resident 64's bed. Review of Resident 64's face sheet indicated Resident 64 admitted to facility on 8/12/2020. Review of Resident 64's physician order, dated 8/12/2020, indicated Resident 64 had an order for upper half rails up when in bed for bed mobility. A review of Resident 64's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:22 p.m., noted both upper side rails up for Resident 19's bed. Review of Resident 19's face sheet indicated Resident 19 admitted to facility on 11/22/2021. Review of Resident 19's physician order, dated 11/22/2021, indicated Resident 19 had an order for upper half rails up when in bed for bed mobility. A review of Resident 19's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:30 p.m., noted both upper side rails up for Resident 41's bed. Review of Resident 41's face sheet indicated Resident 41 admitted to facility on 2/6/2017. Review of Resident 41's physician order, dated 3/6/2019, indicated Resident 41 had an order for upper half rails up when in bed for bed mobility. A review of Resident 41's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:55 p.m., noted both upper side rails up for Resident 7's bed while Resident 7 was not in bed or in room. Review of Resident 7's face sheet indicated Resident 7 admitted to facility on 2/8/2023. Review of Resident 7's admission diagnoses include TIA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 19 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident 7's physician order, dated 2/28/2023, indicated Resident 7 had an order for upper half rails up when in bed for bed mobility. A review of Resident 7's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:00 p.m., noted both upper side rails up for Resident 17's bed. Review of Resident 17's face sheet indicated Resident 17 admitted to facility on 7/6/2021. Review of Resident 17's physician order, dated 7/6/2021, indicated Resident 17 had an order for upper half rails up when in bed for bed mobility. A review of Resident 17's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:15 p.m., noted both upper side rails up for Resident 20's bed. Review of Resident 20's face sheet indicated Resident 20 admitted to facility on 5/20/2017. Review of Resident 20's physician order, dated 3/6/2019, indicated Resident 20 had an order for upper half rails up when in bed for bed mobility. A review of Resident 20's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:20 p.m., noted both upper side rails up for Resident 56's bed. Review of Resident 56's face sheet indicated Resident 56 admitted to facility on 12/8/2020. Review of Resident 56's physician order, dated 12/8/2020, indicated Resident 56 had an order for upper half rails up when in bed for bed mobility. A review of Resident 56's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:35 p.m., noted only left upper side rail up for Resident 37's bed. Review of Resident 37's face sheet indicated Resident 37 admitted to facility on 5/18/2016. Review of Resident 37's physician order, dated 3/6/2019, indicated Resident 37 had an order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 20 of 31 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 03/19/2024 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 0700 upper half rails up when in bed for bed mobility. Level of Harm - Minimal harm or potential for actual harm A review of Resident 37s clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. Residents Affected - Many During an initial observation on 3/11/2024 at 1:50 p.m., noted both upper side rails up for Resident 70's bed. Review of Resident 70's face sheet indicated Resident 70 admitted to facility on 7/27/2023. Review of Resident 70''s admission diagnoses include diabetes type 2 (too much sugar in the body), and depression. Review of Resident 70's physician order, dated 7/27/2013, indicated Resident 70 had an order for upper half rails up when in bed for bed mobility. A review of Resident 70's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:52 p.m., noted both upper side rails up for Resident 32's bed. Review of Resident 32s face sheet indicated Resident 32 admitted to facility on 3/23/2022. Review of Resident 32's physician order, dated 3/23/2022, indicated Resident 32 had an order for upper half rails up when in bed for bed mobility. A review of Resident 32's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 2:06 p.m., noted both upper side rails up for Resident 48's bed. Review of Resident 48's face sheet indicated Resident 48 admitted to facility on 5/24/2021. Review of Resident 48's admission diagnoses include diabetes 2, and TIA. Review of Resident 48's physician order, dated 4/17/2023, indicated Resident 48 had an order for upper half rails up when in bed for bed mobility. A review of Resident 38's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation on 3/12/2024 at 9:53 a.m., noted left upper side rail up, and right upper side rail down for Resident 14's bed. Review of Resident 14's face sheet indicated Resident 14 admitted to facility on 11/12/2018. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 21 of 31 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 03/19/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident 14's physician order, dated 11/12/2018, indicated Resident 14 had an order for upper half rails up when in bed for bed mobility. A review of Resident 14's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an interview with certified nursing assistant R (CNA R) on 3/15/2024 at 10:00 a.m., CNA R stated both upper side rails up all residents in south building since residents admitted to facility. During an interview with CNA S on 3/15/2024 at 10:30 a.m., CNA S stated both upper side rails were in use to facilitate turning, repositioning and get in and out of the bed for all residents in south building. During an interview with registered nurse A on 3/15/2024 at 10:37 a.m., RN A confirmed both upper side rails were in use for Resident 30, 7, 48, 70, 32, 54, 27, 79, 78, 64, 20, 53, 15, 41, 25, 62, 19, 56, 37, 14, 39 17, and Resident 49's beds. RN A stated there was no informed consent for side rails upon the admission to facility for all these residents. RN A also acknowledged there was no education for risk and benefits not provided, no assessment for side rails for risk of resident's entrapment, and no attempts of alternatives for side rails prior to started using both upper side [NAME] for all these residents. RN A further stated nursing staff should have completed assessment for side rails, attempted alternatives to side rails and taken informed consent prior to started using side rails for above all residents. During an interview with director of nursing (DON) on 3/15/2024 at 11:14 a.m., DON confirmed both upper side rails were in use for all above residents. DON also acknowledged there was no nursing documentation for assessment for side rails for risk for entrapment, attem FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 22 of 31 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 03/19/2024 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 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 had a medication error rate of 5.88% when two medication errors occurred out of 34 opportunities during the medication administration for two of 12 residents (Residents 30 and 31). Both residents did not receive their medications as ordered. The failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications. Residents Affected - Few Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 3/11/24 at 11:49 a.m., she was observed giving two medications to Resident 30 including a bottle of Systane Lubricant Eye drops. At the bedside, RN A instilled one drop of Systane eye solution into each of the resident's eyes. A review of Resident 30's physician's order, dated 10/9/22, indicated for Refresh Tears Solution (Carboxymethylcelulose Sodium) [active ingredient, a type of lubricant], to instill 1 drop in both eyes three times daily for dry eyes. During a concurrent interview and record review with RN A on 3/11/24 at 2:09 p.m., a review of the active ingredients on the Systane Lubricant Eye drops (used earlier for Resident 30) indicated two lubricant products: polyethylene glycol 0.4% and propylene glycol 0.3%. RN A confirmed the physician's order indicated Refresh Tears Solution while she administered Systane Eye drops. She acknowledged both products were not the same as they did not have the same active ingredients. 2. During an interview on 3/11/24 at 4:05 p.m., in front of Resident 31's room, RN B stated she was being oriented by RN C on medication administration. On 3/11/24 at 4:07 p.m. in the presence of RN C, RN B was observed preparing a medication for Resident 31. She poured 5 milliliters (mL, unit of measurement) of valproic acid (a medication to manage seizures) 250 milligrams (mg) per 5 mL into a small medication cup. On 3/11/24 at 4:11 p.m., RN B was observed bringing the 5-mL valproic acid liquid cup along with a 30-mL cup of water into Resident 31's room. At the resident's bedside, she disconnected the resident's enteral tube and checked the resident residual volume (the amount of liquid drained from a stomach following administration of enteral feed) and the tube placement. Then, RN B attached the syringe to the resident's gastrostomy tube (also called a G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) and poured the valproic acid liquid into the tube without flushing the tubing with water first. During an interview on 3/11/24 at 4:26 p.m., in the presence of RN C, RN B acknowledged she should have flushed the resident's enteral tubing with water first before pouring the medication into it. A review of Resident 31's physician's order, dated 10/27/23, indicated to give valproic acid solution 250 mg/5mL, give 500 mg via G-tube two times a day related to UNSPECIFIED CONVULSIONS. During a concurrent interview and record review with RN B and RN C on 3/11/24 at 5:08 p.m., they reviewed Resident 31's physician's order for valproic acid and confirmed it indicated to give 500 mg (or 10 mL). A review of the pharmacy label on the valproic acid bottle also indicated to GIVE 500 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 23 of 31 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 03/19/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm = (10 ML) BY MOUTH VIA G-TUBE TWO TIMES A DAY. Both nurses confirmed it was an error by giving only 5 mL. RN C stated, We will give another 5 mL now. During an interview with the Director of Nursing (DON) on 3/12/24 12:22 p.m., she stated the resident's G-tube should be flushed with water before, between, and after medication administration. Residents Affected - Few A review of the facility's policy and procedures (P&P) titled Medication Administration, dated 1/2021, indicated: Medications are administered in accordance with written orders of the prescriber. Regarding the medication administration through the enteral tubes, the P&P indicated: Enteral tubes are flushed with at least 15 mL of water before administering any medications and after all medications have been administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 24 of 31 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 03/19/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when insulin (medication to lower blood sugar) pens were not labeled with an expiration date when stored at room temperature; expired medications were identified in two of two medication carts, and in two of two medication rooms; and the temperature was not being monitored and maintained twice daily for two out of two medication refrigerators as per facility policy and procedures (P&P). This failure had the potential for the insulin to be administered past the 28-day expiration date; expired medications given to the residents; and loss of drug potency due to unmonitored temperatures. Findings: 1. During a visit to the Northside Medication Room with Licensed Vocational Nurse (LVN) D on 3/11/24 at 9:21 a.m., the medication refrigerator was identified. A quick review of the contents inside reflected it contained several refrigerated medications including two boxes of flu vaccine and two syringes of pneumococcal vaccine (help prevent infections caused by certain types of bacteria called pneumococcus). LVN D stated the staff monitored the refrigerator temperature twice daily (day shift and night shift). A review of the temperature logs (in a binder) with LVN D indicated the staff did not consistently monitor the temperature during the day shift. The monitoring was missing (not documented) 3 days in December 2023, 3 days in January 2024, and 1 day in March 2024. LVN D verified the refrigerator temperature log was incomplete. During this visit to the medication room with LVN D, two out of two Epipens (life-saving medication used when someone is experiencing a severe allergic reaction, known as anaphylaxis) were identified in a medication drawer with an expiration date of 9/2023. LVN D confirmed the Epipens were expired. 2. On 3/11/24 at 9:42 a.m., an inspection of Team 1 Medication Cart (on Northside) was inspected with LVN E. Two Basaglar KwikPens (pre-filled pens containing long-acting insulin) for two residents were stored at room temperature and without a written expiration date, and one of one Glutose 15 (oral glucose gel - used to treat low blood sugar levels) with an expiration date of 2/29/24. LVN E confirmed the Glutose 15 had expired and the insulin pens had no expiration date. She stated they were unopened. For Basaglar KwikPen storage, a review of the Lexi-comp, a nationally known drug information resource, indicated to store unopened prefilled pens at room temperature . for 28 days. 3. On 3/11/24 at 10:18 a.m., an inspection of the Medication Cart on Southside with Registered Nurse (RN) A identified a bottle of famotidine (medication to treat stomach upset) that had an expiration date of 1/2024. RN A confirmed this finding. 4. During a visit to the Southside Medication Room on 3/11/24 at 9:30 a.m., the medication refrigerator was identified. It contained numerous refrigerated medications including several syringes of flu vaccine. A review of the temperature logs, from June 2023 to March 2024, indicated they were incomplete or not logged during the day shift: 4 days in September 2023, 6 days in October 2023, and 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 25 of 31 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 03/19/2024 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 0761 days in February 2024. RN A acknowledged the missing temperature monitoring. Level of Harm - Minimal harm or potential for actual harm Additionally, the following expired products were identified and confirmed with RN A during this same visit: - Two of two Glutose15 tubes: expired [DATE] Residents Affected - Few - Two of two boxes, each containing 100 counts of zinc sulfate 220 milligrams (a mineral used to replenish low levels of zinc or prevent zinc deficiency): expired 2/2024 - A tray containing 16 (sixteen) 10-mL single vials of sterile water for injection (a diluent to mix with intravenous products): expired 12/2023. During an interview with the Director of Nursing (DON) on 3/12/24 at 12:22 p.m., she stated her expectation is that the staff monitor medication refrigerator twice daily to make sure the temperature is within range because the efficiency of meds depends on the temp. A review of the facility's P&P titled Storage of Medications, dated 1/2021, indicated: Medications and biologicals are store properly, following manufacturer's or provider pharmacy recommendation, to maintain their integrity and to support safe effective drug administration, The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily, Insulin products should be stored in the refrigerator until opened, and Outdated . medications . are immediately removed from stock . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 26 of 31 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 03/19/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to ensure to accommodate food dislikes for one out of three sampled residents (Resident 58). This failure had the potential for decreased meal intake and negative effects on health and well-being for Resident 58. Findings: During lunch observation in the facility's south building's dining room on 3/11/2024 at 12:23 p.m., cut pieces of carrots along with other food items were on Resident 58'slunch plate. Review of Resident 58's lunch tray card, dated 3/11/2024, indicated under dislikes No: Carrots, Cauliflower. Review of facility's lunch menu for 3/11/2024 indicated carrots lyonnaise along with other food items. During a concurrent interview, and record review of Resident 58's lunch tray card with certified nursing assistant K (CNA K), on 3/11/2024 at 12:30 p.m., CNA K acknowledged carrots under dislikes for Resident 58. CNA K stated dietary staff should not have provided carrots to Resident 58 as indicated under food dislikes for Resident 58. During an interview with facility's certified dietary manger L (CDM L) on 3/11/2024 at 12:36 p.m., CDM L confirmed Resident 58's lunch tray card indicated carrots under food dislikes; however, Resident 58 received carrots for lunch. CDM L stated dietary staff should not have served carrots to Resident 58. During a concurrent interview and record review of Resident 58's lunch tray card with facility's registered dietitian (RD) on 3/15/2024 at 12:25 p.m., RD stated dietary staff should have read food dislikes and not served carrots for Resident 58 for lunch on 3/11/2024. Review of facility's policy and procedure (P&P) titled, Dietary Services, effective 02/96, indicated, Special requests by residents are sent, in writing to dietary. Resident receives those special requests unless contraindicated by diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 27 of 31 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 03/19/2024 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 record review the facility failed to ensure sanitary practices of both kitchens and their foods were stored under sanitary conditions when: Residents Affected - Some 1. A wilted head of lettuce, green onion, and cut salad were stored in a refrigerator; 2. No air gap (space between the top of the drain overflow and the discharge pipe or hose to prevent back flow of contaminated water) for a dishwasher, ice machine, 3-way sink (commercial and manual dishwashing sink), and food preparation sink in kitchen; 3. The egg salad stored in a refrigerator was measured at 44.5 degrees Fahrenheit (a unit of measurement of temperature) These failures had the potential to result in food borne illnesses among residents in the facility. Findings: 1.During an initial kitchen 1 observation and interview with facility's certified dietary manager L (CDM L) on 3/11/24 at 10:00 a.m., a wilted, brown colored head of lettuce, yellow and black colored wilted bunch of green onion leaves, and wilted cut salad in a plastic bag were in a refrigerator in kitchen 1. CDM L acknowledged these observations. CDM L discarded all three items, and stated dietary staff should have discarded them from the refrigerator. 2.During an initial kitchen 2 observation with facility's CDM M on 3/11/2024 at 4:00 p.m., there was no air gap for the dishwasher, ice machine, 3-way sink, and food preparation sink in kitchen 2. During an interview with CDM M on 3/11/2024 at 4:10 p.m., CDM M acknowledged there were no air gaps for these four items in the kitchen 2. CDM M stated there should be air gaps for all of the four items according to safe sanitary practices. During an interview with facility's plant operations manager (POM) on 3/13/2024 at 2:34 p.m., POM confirmed there were no air gap or back flow devices in kitchen 2 for above four areas. POM stated this building old, grandfathered and followed old plumbing requirements when kitchen 2 was built. POM also stated above four areas should have air gaps to prevent potential back flow of contaminated water from sewage line. POM further stated there was no facility's policy and procedure for air gap. 3. During a follow up kitchen 2 observation and interview with CDM M on 3/14/2024 at 4:07 p.m., the egg salad in a refrigerator measured 44.5-degree Fahrenheit. CDM M acknowledged above finding. CDM M discarded the egg salad. CDM M stated cold foods should be stored at equal or below 40-degrees Fahrenheit in the refrigerator. During an interview with facility's registered dietitian (RD) on 3/15/2024 at 12:02 p.m., RD stated dietary staff should have verified and discarded wilted, color changed vegetables from refrigerator in kitchen 1. RD also stated dietary should have discarded foods from refrigerator that should be cold with temperatures above 40 -degrees Fahrenheit in kitchen 2. RD further stated there was a risk for water backflow and a contamination of the water supply for kitchen 2 for the aforementioned items without air gaps. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 28 of 31 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 03/19/2024 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 Residents Affected - Some Review of facility's policy and procedure (P&P) titled, Shelf Life of Fruit and Vegetable Products, reviewed 2/2022, the P&P indicated, PM [NAME] (or CDM) will inspect fruits and vegetables daily. Produce showing signs of spoilage or color change will be discarded immediately. Review of Food & Drug Administration (responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices: and by ensuring the safety of nation's food supply .) 's Food Code 2022 for 5-202.13 Backflow Prevention, Air Gap guidelines indicated An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, Or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). Review of facility's P&P titled, Label & Dating Guidelines, reviewed 2/2024, indicated, Cold foods, left over Storage/Holding Temperature 40-degree Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 29 of 31 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 03/19/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. During a medication administration observation on 3/11/24 at 4:42 p.m., Registered Nurse (RN) F was observed getting the shared BP cart (containing the BP monitor and cuff) from the hallway and bringing it to Resident 82's room. At the resident's bedside, RN F wrapped the BP cuff around Resident 82's right upper arm to check the BP without disinfecting it first. Residents Affected - Few After administering a medication to the resident, on 3/11/24 at 4:49 p.m., RN F brought the BP cart back out to the hallway and placed it by the medication cart. She did not disinfect the BP cuff after use. In an interview on 3/11/24 at 4:51 a.m., RN F stated the BP cart was being shared among residents. She confirmed she did not disinfect the BP cuff before and after use for Resident 82. She stated she was not sure if it should be disinfected, saying that maybe the previous user already wiped it down. However, RN F acknowledged she would not have known if the previous user cleaned it after use, as she did not clean it after use. During an interview with the Director of Nursing (DON) on 3/12/24 at 12:22 p.m., she stated shared equipment, such as the BP cuff, should be disinfected before and after use; such that, if the nurse took it from the hallway, and there is no sign or label indicating it was cleaned/disinfected by the previous user, the nurse should clean it before using it on the next resident. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Patient Care Equipment, revised on 1/30/22, indicated the facility staff ensuring the non-critical resident-care items (are those that come in contact with intact skin but not mucous membranes), including blood pressure cuffs, are cleaned with the hospital-approved detergent/disinfectant before use and that all used or contaminated equipment is appropriately cleaned before reuse, and If it is unclear whether patient care equipment has been cleaned, it must be cleaned before patient use. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control practice to prevent the spread of infection when: 1. A nasal cannula (NC: a medical device to provide supplemental oxygen to residents) tubing was on the floor, and dated 3/3; 2. A Foley catheter (F/C: a semi-flexible plastic tube, one end inserted into the bladder [body organ that stores urine] and the other end is attached to a bag that collects urine) drain bag's cover touched the floor; 3. Nursing staff failed to disinfect the shared blood pressure (BP) cuff (the device used to measure BP) before and after use for Resident 82. These failures had the potential for the spread of infections and communicable diseases among residents. Findings: 1.During an observation on 3/11/2024 at 10:38 a.m., NC tubing, that was dated 3/3, and was attached to a room air concentrator (RAC: a medical device that take in air from the room and filter out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 30 of 31 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 03/19/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nitrogen to provides higher amounts of oxygen) lay on the floor next to nightstand when it was not in use in Resident 54's room. During an interview with registered nurse A (RN A) on 3/11/2024 at 10:51 a.m., RN A confirmed the NC tubing was on the floor and that it was dated 3/3. RN A stated NC tubing needs to changed every week and to keep the tubing in a storage bag when not in use. RN A also stated staff should have changed NC tubing on 3/10/2024, and placed the tubing in a storage bag when oxygen was not in use per standard infection control practices. 2. During an observation on 3/11/2024 at 2:06 p.m., a drainage bag's privacy cover touched the floor for Resident 48. During an interview with certified nursing assistant J (CNA J) on 3/11/2024 at 2:18 p.m., CNA J confirmed Resident 48's Foley catheter drainage bag's cover touched the floor. CNA J stated the drainage bag should be off the floor. During an interview with RN I on 3/12/2024 at 9:44 a.m., RN I stated Resident 48's Foley catheter drainage bag's cover should be off the floor for infection control purposes. During an interview with facility's infection preventionist (IP) on 3/13/2024 at 10:58 a.m., IP stated the Foley catheter drainage bag's cover should be above the floor. During an interview with the facility's IP on 3/13/2024 at 11:15 a.m., IP stated the NC tubing should have been changed every week and placed in a storage bag when not in use to follow standard infection control practices. Review of facility's policy and procedure (P&P) titled, Oxygen Safety, effective 12/07, indicated, Oxygen tubing should be coiled without kinks and placed in the storage bag, this is to prevent tripping and promote optimal infection control. Nasal Cannulas, simple masks or non-rebreathing mask will also be changed every 7 days and as needed. Review of facility's policy and procedure (P&P) titled, Catheter-Urinary Retention-Insertion, effective 2/95, indicated, Ensure that the emptying base of the drainage bag is closed. Secure the drainage bag to the bed frame using the hook or strap provided. Suspend the bag off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 31 of 31