Health inspection·December 12, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice related to pain management for one of four sampled residents (Resident 1) when Resident 1 did not receive the right dosage of oxycodone (a controlled drug used to treat moderate to severe pain) to manage severe pain to right hip. This failure had the potential to affect Resident 1's well-being. Residents Affected - Few Findings: Review of Resident 1's clinical record titled, admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced subtrochanteric fracture of right femur (a severe injury to the thigh bone where the fractured ends is out of alignment), aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with new, artificial part), polyneuropathy (multiple nerve damage), presence of right artificial hip, and need assistance with personal care. Review of Resident 1's 5-day minimum data set (MDS, federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 13 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review revealed, Resident 1 had frequently experienced pain, and frequently limited her participation in rehabilitation therapy (a form of treatment to restore function to those recovering from an injury or surgery) sessions, and day to day activities because of pain over the last 5 days. Review of Resident 1's clinical record titled, Order Summary Report, indicated an order of oxycodone hydrochloride (HCl)10 milligrams (mg, unit of measurement) every 6 hours as needed for moderate to severe pain which was ordered on 11/30/2024. Review of Resident 1's list of care plan titled, The resident had pain ., date initiated 12/2/2024, indicated, Anticipate the resident's needs for pain relief and respond immediately to any complaint of pain .Monitor Pain every shift and PRN [pro re nata - as the need arises] when giving PRN meds [medications] (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10= severe pain). Review of Resident 1's December medication administration record (MAR, a record of medications given), indicated an order of oxycodone HCl 5 mg started on 11/30/2024, to be given every 6 hours as needed for moderate pain (4-6 pain scale). Further review indicated on 12/1/2024 at 2:36 a.m., Resident 1 had pain scale of 8 (severe pain) and on 12/2/2024 at 6:00 a.m., Resident 1 had pain scale of 7 (severe pain). Resident 1 was given 5 mg of oxycodone HCl on both times which was indicated for (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055462 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055462 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 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)