Health inspection·September 19, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for one of 22 sampled residents (Resident 34) when Resident 34's MDS assessment did not reflect the use of antipsychotic medication (used to treat psychosis and other mental health disorders). This failure resulted in an inaccurate MDS assessment, which had the potential to affect the resident's care.Findings:Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm).Review of Resident 34's physician orders indicated she had orders for Seroquel 25 milligrams (mg, unit of measurement) two times a day for agitation, delusion, and paranoia, dated 9/13/25. Review of Resident 34's previous physician orders indicated she had orders for Seroquel starting in 11/2024.Review of Resident 34's Minimum Data Set (MDS, an assessment tool), dated 7/24/25 indicated the resident was taking an antipsychotic. The MDS further indicated, No - Antipsychotics were not received for the question, Did the resident receive antipsychotic medications .?During an interview on 9/19/25 at 1:26 p.m., the MDS Coordinator (MDS) stated the answer should be, Yes. The MDS stated she will submit a modification. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 2 of 20 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 09/19/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include instructions on the care of bed rails or side rails (adjustable rigid bars attached to the side of a bed) use for one (Resident 99) of 36 residents (residents with bed rails or side rails). This failure resulted in the installation and use of Resident 99's bed rails without a plan of care. This failure had the potential to result in Resident 99's serious injury.Findings:Review of Resident 99's clinical record titled, admission Record, dated 9/18/2025, indicated Resident 99 was admitted to the facility on [DATE] with diagnoses including non-displaced fracture (broken bone) of lesser trochanter of left femur (a small, cone-shaped bony bump on the inside, back part of the upper thigh bone [femur], near the neck of the bone joins the shaft), epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures), and hyponatremia (a condition where the sodium level in the blood is too low).Review of Resident 99's clinical record titled, SNF [Skilled Nursing Facility]-Side Rail Assessment Form, dated 9/12/2025, indicated alternatives were attempted prior to bed rail or side rail use like bed was lowered, adequate lighting, call light was provided and a trapeze bar was used but unsuccessful. Further review, the interdisciplinary team's (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) decision based on the assessment indicated, YES-APPROPRIATE FOR UPPER SIDE RAIL USE.During an observation on 9/15/2025 at 11:04 a.m., inside Resident 99's room, Resident 99 was in bed, with four bed rails installed on his bed and the two upper bed rails were in upright position.During a concurrent observation and interview with registered nurse A (RN A) on 9/17/2025 at 1:27 p.m., inside Resident 99's room, Resident 99 was in bed and the bed had two upper bed rails in upright position. RN A confirmed the above observation and stated Resident 99 had been using the bed rails for mobility.During a concurrent interview with director of staff development (DSD) and record review on 9/17/2025 at 4:01 p.m., the DSD reviewed Resident 99's list of care plans and confirmed there was no baseline care plan related to bed rail use. The DSD further confirmed Resident 99 was admitted to the facility on [DATE].During an interview with licensed vocational nurse B (LVN B) on 9/19/2025, LVN B confirmed the use of bed rails for new admission should be included in the baseline care plan.During a review of the facility's policy and procedure titled, Plan - Resident Care, date reviewed 10/2010, indicated, A resident Care Plan will be initiated upon admission. Event ID: Facility ID: 055462 If continuation sheet Page 3 of 20 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 09/19/2025 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 individualized, resident-centered care plans for 24 of 36 residents (Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6) who used bed rails or side rails (adjustable rigid bars attached to the side of a bed).These failures had the potential of unmet care needs for Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6's use of bed rails. Findings: 1. During an observation on 9/15/2025 at 10:42 a.m., inside Resident 84's room, Resident 84 was on bed with two bed rails installed and in an upright position. During a concurrent observation and interview with registered nurse A (RN A) on 9/17/2025 at 1:20 p.m., inside Resident 84's room, Resident 84's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 84 used the upper bed rails to assist her with mobility and transfers. The RN A further stated the use of bed rails should be care planned. During a concurrent interview with the director of staff development (DSD) and record review on 9/17/2025 at 3:40 p.m., the DSD reviewed Resident 84's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 2. During an observation on 9/15/2025 at 10:49 a.m., inside Resident 22's room, Resident 22 was not in the room. There were four bed rails installed on her bed, and the two upper bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:21 p.m., inside Resident 22's room, Resident 22's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 22 used the upper bed rails to assist her with mobility and transfers. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:48 p.m., the DSD reviewed Resident 22's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 3. During an observation on 9/15/2025 at 10:50 a.m., inside Resident 28's room, Resident 28 was seated on his wheelchair. There were four bed rails installed on his bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:24 p.m., inside Resident 28's room, Resident 28's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 28 used the upper bed rails to assist him with mobility and transfers. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:51 p.m., the DSD reviewed Resident 28's list of care plans and confirmed there was no specific care plan developed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 4 of 20 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 09/19/2025 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 the use of bed rails. Level of Harm - Minimal harm or potential for actual harm 4. During an observation on 9/15/2025 at 10:58 a.m., inside Resident 97's room, Resident 97 was on the bed, there were four bed rails installed on her bed, and the upper two bed rails were in an upright position. Residents Affected - Some During a concurrent observation and interview with the RN A on 9/17/2025 at 1:25 p.m., inside Resident 97's room, Resident 97's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 97 used the upper bed rails. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:54 p.m., the DSD reviewed Resident 97's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 5. During an observation on 9/15/2025 at 11:02 a.m., inside Resident 98's room, Resident 98 was on the bed, there were four bed rails installed on her bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:26 p.m., inside Resident 98's room, Resident 98's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 98 used the upper bed rails. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:59 p.m., the DSD reviewed Resident 98's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 6. During an observation on 9/15/2025 at 11:04 a.m., inside Resident 9's room, Resident 9 was not in the room, there were four bed rails installed on his bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:27 p.m., inside Resident 9's room, Resident 9's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 9 used the upper bed rails During a concurrent interview with the DSD and record review on 9/17/2025 at 4:04 p.m., the DSD reviewed Resident 9's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 7. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:34 p.m., inside Resident 60's room, Resident 60's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 60 used the upper bed rail for transfers and bed mobility. During a concurrent interview with the DSD and record review on 9/17/2025 at 4:08 p.m., the DSD reviewed Resident 60's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. During a review of the facility's policy and procedure titled, Plan – Resident Care, date reviewed 10/2010, indicated, A resident Care Plan will be initiated upon admission and completed within 14 days of admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 5 of 20 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 09/19/2025 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 8. During an observation on 9/15/25 at 12:52 p.m., in Resident 91's room, Resident 91 was not in the room. Resident 91's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:40 p.m., the DSD reviewed Resident 91's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails. 9. During an observation on 9/15/25 at 12:55 p.m., in Resident 58's room, Resident 58 was not in her room. Resident 58's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:43 p.m., the DSD reviewed Resident 58's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails 10. During an observation on 9/15/25 at 12:56 p.m., in Resident 83's room, Resident 83 was seated in the room. Resident 83's bed had two upper side rails installed During a concurrent interview and record review with the DSD on 9/18/25 at 1:37 p.m., the DSD reviewed Resident 83's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails. 11. During an observation on 9/15/25 at 12:57 p.m., in Resident 2's room, Resident 2 was sitting upright in bed, eating lunch and the bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:28 p.m., the DSD reviewed Resident 2's list of care plan and confirmed that a specific care plan for bed rail use has not been developed. The DSD further confirmed that there were no focused care plans concerning bed rails. 12. During an observation on 9/15/25 at 12:58 p.m., in Resident 54's room, Resident 54 was in a wheelchair eating lunch and watching TV. Resident 54's bed had upper side rails installed. During a concurrent interview and record review with the director of staff development (DSD) on 9/18/25 at 1:46 p.m., the DSD reviewed Resident 54's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails for Resident 54. 13. During an observation on 9/15/25 at 12:59 p.m., in Resident 50's room, Resident 50 was in her wheelchair and maneuvered herself back to her bed. Resident 50's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:50 p.m., the DSD reviewed Resident 50's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails for Resident 50. 14. During an observation on 9/15/25 at 1:07 p.m., in Resident 5's room, Resident 5 was seated in a wheelchair while watching television (TV). Resident 5's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:29 p.m., the DSD reviewed Resident 5's list of care plans and confirmed there were no specific care plans that had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 6 of 20 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 09/19/2025 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 developed for the use of bed rails for Resident 5. Level of Harm - Minimal harm or potential for actual harm 15. During an observation on 9/15/25 at 1:13 p.m., in Resident 10's room, Resident 10 was seated in the wheelchair while watching TV. Resident 10's bed had two upper side rails installed. Residents Affected - Some During a concurrent interview and record review with the DSD on 9/18/25 at 1:31 p.m., the DSD reviewed Resident 10's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails for Resident 10. During a review of the facility's policy and procedure titled, Plan – Resident Care, date reviewed 10/2010, indicated, .A resident Care Plan will be initiated upon admission and completed within 14 days of admission; The written care plan will be reviewed and revised at the Resident Care Conference by the Interdisciplinary team within 14 days of admission; Resident Care Plans will be reviewed and revised as needed at least every 3 months at Resident Care Conference. 16. During an observation on 9/16/2025 at 9:20 a.m. in Resident 34's room, Resident 34's bed had bilateral side rails. Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm). Review of Resident 34's Acknowledgment of Assistive/Enabling Device use, dated 2/1/24 indicated it was medically necessary for upper half side rails for Resident 34. Review of Resident 34's care plans indicated there was no care plan regarding the use of mobility bars. 17. During an observation on 9/16/2025 at 9:41 a.m. in Resident 80's room, Resident 80's bed had bilateral side rails. Review of Resident 80's clinical record indicated she was admitted to the facility with diagnoses including hypotension (low blood pressure) and ataxia (poor muscle control that affects balance and coordination). Review of Resident 80's physician orders indicated she had an order, dated 7/31/25 for upper mobility bars up when in bed for bed mobility. Review of Resident 80's Side Rail Assessment Form, dated 7/30/25 indicated bilateral upper half rails were recommended. Review of Resident 80's care plans indicated there was no care plan regarding the use of mobility bars. During an interview on 9/19/2025 at 10:39 a.m., Licensed Vocational Nurse B (LVN B) confirmed Residents 34 and 80 did not have a separate care plan for mobility bars and should have had one. 18. During the observation of Resident 33 on 9/15/25 at 12:40 p.m., Resident 33 was sitting in her wheelchair. She was alert, calm, comfortable and verbally responsive. Resident 33 had her bilateral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 7 of 20 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 09/19/2025 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 upper half side rails up. Level of Harm - Minimal harm or potential for actual harm Review of Resident 33's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, she was admitted to the facility on [DATE]. Residents Affected - Some Review of Resident 33's care plans indicated, Resident 33 did not have an individualized, resident-centered care plan for the side rails. 19. During the observation of Resident 41 on 9/15/25 at 12:42 p.m., Resident 41 was eating her lunch. She was alert, calm, comfortable and verbally responsive. Resident 41 had her bilateral upper half side rails up. Review of Resident 41's admission record indicated, she was admitted to the facility on [DATE]. Review of Resident 41's care plans indicated, Resident 41 did not have an individualized, resident-centered care plan for the side rails. 20. During the observation of Resident 75 on 9/15/25 at 12:52 p.m., Resident 75 was sitting in her wheelchair. She was alert, comfortable and verbally responsive. Resident 75 had her bilateral upper half side rails up. Review of Resident 75's admission record indicated, she was admitted to the facility on [DATE]. Review of Resident 75's care plans indicated, Resident 75 did not have an individualized, resident-centered care plan for the side rails. 21. During the observation of Resident 64 on 9/15/25 at 12:54 p.m., Resident 64 was eating lunch in his room. He had his bilateral upper half side rails up. Review of Resident 64's admission record indicated, he was admitted to the facility on [DATE]. Review of Resident 64's care plans indicated, Resident 64 did not have an individualized, resident-centered care plan for the side rails. 22. During the observation of Resident 20 on 9/15/25 at 12:58 p.m., Resident 20 was in the dining room, eating his lunch. Checked his bed and he had his bilateral upper half side rails up. Review of Resident 20's admission record indicated, he was readmitted to the facility on [DATE]. Review of Resident 20's care plans indicated, Resident 20 did not have an individualized, resident-centered care plan for the side rails. 23. During the observation of Resident 66 on 9/15/25 at 1:01 p.m., Resident 66 was in the dining room, eating his lunch with total assistance from the facility staff. Checked his bed and he had his bilateral upper half side rails up. Review of the admission record of Resident 66 indicated, he was 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 8 of 20 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 09/19/2025 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 Review of the care plans of Resident 66 indicated, Resident 66 did not have an individualized, resident-centered care plan for the side rails. 24. During the observation of Resident 6 on 9/15/25 at 1:01 p.m., Resident 6 was in his room eating his lunch. He was alert and verbally responsive. Resident 6 had his bilateral upper half side rails up. Residents Affected - Some Review of the admission record of Resident 6 indicated, he was readmitted to the facility on [DATE]. Review of the care plans of Resident 6 indicated, Resident 6 did not have an individualized, resident-centered care plan for the side rails. During the concurrent review of the residents' care plans and interview with the DSD on 9/19/25 at 10:33 a.m., the DSD verified that Residents 33, 41, 75, 64, 20, 66, and 6 had bilateral upper half side rails that were up. DSD further verified that these residents did not have individualized, resident-centered care plans for their side rails. She then stated that she would update their care plans. During the interview with the interim director of nursing (IDON) on 9/19/25 at 12:59 p.m., IDON confirmed that the above residents did not have individualized, resident-centered care plans for their side rails and she would follow up on these concerns. Review of the facility's policy and procedure titled, Plan - Resident Care, reviewed on 10/2010 indicated, Basic Requirements of Care Plans: date, identifiable needs and problems, measurable and time-limited goals, approaches for accomplishing goals, discipline responsible for approach, evaluation Problems are added and goals set as conditions arise FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 9 of 20 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 09/19/2025 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 - Few 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** Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for four (Residents 97, 99, 100, and 3) of 36 residents (residents who used bed or side rails) when:1.The physician's orders and informed consents (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not obtained prior to use of bed or side rails for Resident 97 and Resident 99; and,2.Resident 100 and Resident 3 used side rails without a clinically appropriate indication.These failures had the potential to place Residents 97, 99, 100, and 3 at risk of entrapment and serious injury. Findings: 1a. During an observation on 9/15/2025 at 10:58 a.m., inside Resident 97's room, Resident 97 was in bed with four bed rails installed and the two upper bed rails were in an upright position. During a review of Resident 97's clinical records, there was no physician's order and informed consent obtained prior to use of bed rails. During a concurrent interview with the director of nursing (DSD) and record review on 9/17/2025 at 3:54 p.m., the DSD reviewed Resident 97's Side Rail Assessment, admission Record, Side Rail use consent, and order summary report. The DSD confirmed the following: a. Resident 97 was admitted to the facility on [DATE]; b. The Side Rail Assessment was completed on 9/9/2025 which indicated the use of the upper side rails were appropriate for Resident 97; and the informed consent and physician's order were just obtained on 9/16/2025. The DSD stated the informed consent and physician's order should have been obtained first prior to implementation of bed rail use. 1b. During an observation on 9/15/2025 at 11:04 a.m., inside Resident 99's room, Resident 99 was in bed with four bed rails installed and the two upper bed rails were in an upright position. During a review of Resident 99's clinical records, there was no physician's order and informed consent obtained prior to use of bed rails. During a concurrent interview with the DSD and record review on 9/17/2025 at 4:01 p.m., the DSD reviewed Resident 99's Side Rail Assessment, admission Record, Side Rail use consent, and order summary report. The DSD confirmed the following: a. Resident 99 was admitted to the facility on [DATE]; b. The Side Rail Assessment was completed on 9/12/2025 which indicated the use of the upper side rails were appropriate for Resident 97; and the informed consent and physician's order were just obtained on 9/16/2025. During an interview with licensed vocational nurse B (LVN B) on 9/19/2025 at 9:55 a.m., LVN B confirmed residents could use bed rails if the assessment was completed and it indicated an appropriate use of bed rails; informed consents and physician orders were obtained; and care plan for bed rails use was developed. During a review of the facility's policy and procedure titled, Side Rail, dated 3/2018, it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 10 of 20 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 09/19/2025 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 indicated a physician's order and resident's consent will be obtained for side rail use. Level of Harm - Minimal harm or potential for actual harm 2a. During an observation on 9/15/2025 at 11:11 a.m., inside Resident 100's room, Resident 100 was asleep in bed with four bed rails installed and the two upper bed rails were in an upright position. Residents Affected - Few During a concurrent observation and interview with registered nurse A (RN A) on 9/17/2025 at 1:29 p.m., inside Resident 100's room, Resident 100 was in bed and her two upper bed rails were in an upright position. RN A confirmed the above observation and stated Resident 100 used the bed rails for bed mobility and transfers. During a concurrent interview with the DSD and record review on 9/17/2025 at 4:07 p.m., the DSD reviewed Resident 100's Side Rail Assessment Form dated 9/8/2025 and confirmed the interdisciplinary team's (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) decision indicated that the side rail use for Resident 100 was not indicated due to lack of medical necessity (refers to healthcare services or supplies that are reasonable and necessary [required for the diagnosis or treatment of an illness, or condition]). The DSD further confirmed she approved and signed Resident 100's Side Rail Assessment on 9/10/2025. The DSD stated Resident 100's side rails should have been lowered and zip tied to the bed frame. 2b.During an observation on 9/18/2025 at 8:50 a.m., inside Resident 3's room, Resident 3 was observed lying in bed with both upper bed rails in the upright position. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) G on 9/18/2025 at 9:03 a.m., Resident 3 remained in bed with both upper bed rails in the upright position. LVN G confirmed the observation and stated that Resident 3's upper bed rails should not have been in the upright position. A review of Resident 3's clinical record revealed no physician order or signed consent authorizing bedside rail use. A review of Resident 3's care plans revealed no care plan addressing the use of bedside rails. A review of Resident 3's Acknowledgment of Assistive/Enabling Device Use (AAD), dated 6/18/2024, indicated that the rails/bar must remain down at all times. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/18/2025 at 1:55 p.m., the ADON reviewed Resident 3's clinical record and confirmed that there was no physician order, consent, care plan, or AAD authorizing bedside rail use. The ADON stated that side rail use for Resident 3 was not indicated and that her side rails should remain down at all times. A review of the facility's policy and procedure titled Side Rail, effective 3/2018, indicated: A physician's order will be obtained for side rail use . use of Side Rails must be addressed in the Resident Care Plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 11 of 20 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 09/19/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate accountability of medications and controlled substance (drug or other substance that can be easily abused and are under strict government control) for three of 13 randomly selected residents (Residents 56, 78 and 34) when: 1. Resident 56's Azithromycin (used to treat certain bacterial infections in many different parts of the body) antibiotic was not accounted for and reconciled accurately;2. Resident 78's Sulfamethoxazole -Trimethoprim (Cotrimazole, an antibiotic medication used to treat certain infections that are caused by bacteria) was not accounted for and reconciled accurately; and3. Resident 34's controlled medication was signed out of the Controlled Drug Administration Record (CDAR, an inventory or count sheet) without recording the time the medication was given and did not document in the medication administration record (MAR) as administered. These failures resulted in inaccurate accountability of medications and controlled substance which could potentially result in misuse or diversion. Findings: 1. During the concurrent inspection observation and interview with the director of staff development (DSD) on 9/15/25 at 10:28 a.m., checked the drawer for the controlled substances or medications of medication cart 1 (MC 1), where the antibiotics of residents were also stored. The medication pack containing the Azithromycin 250 milligrams (mg, measure of weight) of Resident 56, had 3 tablets left. Checked the antibiotic medication log (tool to track the patient's antibiotic intake to ensure it is taken correctly) of Resident 56, 4 tablets of Azithromycin 250 mg were still left. DSD verified that 1 tablet of Azithromycin 250 mg was not accounted properly. DSD further verified that the nurse should have signed out the antibiotic in the medication log, once it was taken from the medication pack and given to the resident. During the interview with the licensed vocational nurse D (LVN D) on 9/15/25 at 10:35 a.m., LVN D verified that she was not able to sign out the Azithromycin 250 mg antibiotic tablet when it was given to Resident 56. LVN D further verified that she should have signed the antibiotic medication log of Resident 56 when she took out the Azithromycin from the medication pack. Review of the admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) of Resident 56 indicated, he was admitted to the facility on [DATE]. Review of the order summary report of Resident 56 dated 9/15/25 indicated, Resident 56 had an order of Azithromycin 250 mg tablet, give 2 tablets by mouth one time a day on day one, then give 1 tablet by mouth one time a day for four days. 2. During further concurrent inspection observation and interview with DSD on 9/15/25 at 10:30 a.m., continued to check the drawer for the controlled medications of MC 1. The medication pack containing the Sulfamethoxazole -Trimethoprim, 800 mg -160 mg of Resident 78, had 2 tablets left. Checked the antibiotic medication log of Resident 78, 3 tablets of Sulfamethoxazole -Trimethoprim, 800 mg -160 mg were still left. DSD confirmed that 1 tablet of Sulfamethoxazole -Trimethoprim, 800 mg -160 mg was not accounted properly and would remind nurses about it. During the interview of LVN D on 9/15/25 at 10:35 a.m., LVN D verified that she was not able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 12 of 20 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 09/19/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sign out the Sulfamethoxazole - Trimethoprim 800 mg -160 mg antibiotic as well when she administered it to Resident 78 and would not do it next time. Review of Resident 78's admission record indicated, Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's order summary report dated 9/15/25 indicated, Resident 78 had an order of Sulfamethoxazole-Trimethoprim, 800 mg -160 mg tablet, give 1 tablet by mouth every 12 hours for urinary tract infection (UTI, illness in any part of the urinary tract, the system of organs that makes urine), for 10 days, started on 9/6/25. During the interview with the interim director of nursing (IDON) on 9/19/25 at 12:59 p.m., IDON acknowledged that all medications should be properly accounted for and reconciled. IDON further acknowledged that nurses should have signed the antibiotics out in the antibiotic medication logs, once they took them out from the medication pack and would remind nurses about that. Review of the facility's undated policy and procedure titled, Medication Reconciliation Policy, indicated, This policy outlines the standardized process for performing medication reconciliation to ensure accurate and complete medication information is obtained and communicated at each transition of care. The goal is to prevent medication errors and promote patient safety by verifying and documenting all medications a patient is taking, including prescription Documentation of medication reconciliation will be completed as noted in the contents of the policy. 3. During an interview on 9/19/25 at 12:59 p.m., the IDON stated the narcotic medication should be signed out in the narcotic sheets [CDAR] and recorded in the MAR simultaneously. During a concurrent interview with the DSD and record review on 9/19/25 at 10:43 a.m., the DSD reviewed Resident 34's physician order dated 4/17/2025, CDAR for tramadol (an opioid narcotic medication for pain) HCl [Hydrochloride, a salt form of the drugs used to make it more stable and soluble medication] Oral Tablet 25 milligrams (mg, unit of measurement), 1 tablet, and the July 2025 MAR. The DSD confirmed the following: a. Resident 34 had a physician's order dated 4/17/2025, for tramadol HCl Oral Tablet 25 mg, 1 tablet every 4 hours as needed (PRN) for moderate to severe pain (4-6= moderate pain; 7-10 = severe pain); and b. Nursing staff signed out tramadol HCl 25 mg from the CDAR on 7/8/25 without recording the time the medication was given and did not document in the MAR to indicate the medication was administered to Resident 34. The DSD stated licensed nurses should have documented in the MAR to indicate they had given the medication. During an interview licensed vocation nurse H (LVN H) on 9/19/2025 at 1:14 p.m., LVN H stated that if controlled medication is not recorded accurately, it could lead to a double dose and a medication error. A review of the facility's policy and procedure (P&P) titled, Controlled Drugs: Administration dated 11/17/2022, the P&P indicated, Administration of designated controlled drugs shall be recorded on a Medication Administration Record (MAR) as well as a Controlled Substances Administration Record (CSAR), sometimes referred to as a Controlled Drug Administration Record (CDAR). and the ENTRIES (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 13 of 20 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 09/19/2025 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 0755 include: Date and time of administration to the patient or adjustment to stock. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 14 of 20 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 09/19/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) recommendations for one of 22 residents (Resident 34) were followed-up and acted upon. This failure had the potential for the resident to suffer unnecessary adverse side effects that could negatively impact her physical, mental, and psychosocial well-being.Findings:Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm).Review of Resident 34's physician orders indicated she had orders for gabapentin (medication used to prevent seizures or nerve pain) 100 milligrams (mg, unit of measurement) in the morning and gabapentin 200 mg at bedtime for neuropathic pain, dated 3/2/25.Review of Resident 34's Consultation Report, dated 5/21/25 indicated the pharmacist recommended, Please evaluate these medications [Loratadine, Sertraline, Quetiapine, Gabapentin] as possibly contributing to this fall [Resident 34's fall on 5/14/25] and consider decreasing Gabapentin to 100mg bid [twice a day] If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences.Review of Resident's clinical record indicated there was no documented evidence that adverse consequences of gabapentin were monitored for Resident 34.During an interview on 9/19/25 at 2:05 p.m., Licensed Vocational Nurse B (LVN B) stated she was unable to find further physician documentation. She confirmed there was no monitoring for adverse consequences of gabapentin.Review of the facility's policy, Medication Regimen Review, revised 6/5/24 indicated, Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. Event ID: Facility ID: 055462 If continuation sheet Page 15 of 20 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 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when: 1. Lunch was ready at 9:30 a.m. and was held at hot temperature for hours prior to meal service.2. The correct texture and recipe were not followed for pureed diet. These deficient practices had the potential to result in loss of nutrients and to decrease the food intake of residents and could negatively impact their nutritional status. Findings: 1.During a kitchen observation of the North Side on 9/17/25 at 9:27 a.m. with Dietary Supervisor (DS) and Dietary [NAME] (DC), DC stated she finished preparing pureed food at 9:10 a.m. DC also stated the main lunch dish, Beef Stroganoff, was cooked from scratch and was ready by 9:15 a.m. DS stated, Lunch is usually prepared early. DC showed the metal containers covered in aluminum foil containing food for lunch stored in an oven. DC opened two metal containers and showed white pureed food and beef stroganoff. DC stated the white pureed food was cauliflower. DS stated the temperature in the oven where lunch was stored was 200 F (Fahrenheit, a unit of temperature measurement). DS and DC verified all food to be served for lunch were already cooked. A review of facility's Lunch Menu for 9/17/25 indicated beef stroganoff, noodles, cauliflower with red peppers, wheat bread, apple slices, coffee or tea, milk. During lunch tray line observation on 9/17/25 at 11:45 a.m. with DS and DC, the first food cart containing lunch trays for residents was sent out at 11:53 a.m. During an interview with DS on 9/17/25 at 12:31 p.m., DS stated, Lunch was prepared too early today. A review of facility's Policy and Procedure (P&P) entitled Meal Service Procedures-Food Production, Service and Distribution Standards revised 9/2018, the P&P indicated, PolicyThe Food and Nutrition Services Department develops and maintains a mechanism to ensure the safe and accurate preparation, handling and distribution of food items. To preserve nutrient value . 2.During lunch test tray in the North Side building on 9/17/25 at 12:31 p.m. with Dietary Supervisor (DS), a Regular Diet and Pureed Diet test trays were prepared. DS verified the pureed noodles was not the right consistency and stated it was too thick. DS verified pureed noodles was sticky, lumpy, and bland. DS also verified the Regular Diet tray included cauliflower with red peppers while the Pureed Diet only had pureed cauliflower without any trace of red peppers. DS stated I don't know why she [Dietary Cook] did not include the red peppers. A review of facility's Lunch Menu for 9/17/25 indicated beef stroganoff, noodles, cauliflower with red peppers, wheat bread, apple slices, coffee or tea, milk. A review of Kitchen's Quantified Recipe for pureed Cauliflower w/ Red Peppers indicated ingredients included diced sweet peppers.A review of North Side building's Residents' Diet List indicated 10 residents were on Dysphagia I (pureed texture). A review of facility's Policy and Procedure (P&P) entitled Meal Service Procedures-Food Production, Service and Distribution Standards revised 9/2018, the P&P indicated, .Food Production Standards . To maintain constantly high quality production standards . RECIPES- Maintain and follow a file of standardized recipes. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 16 of 20 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 09/19/2025 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on interview, and document review, the facility failed to review and/or revise their policy and procedure in compliance with federal regulations and with accepted professional standards when the facility did not revise or update their side rail policy and procedure annually. This failure had the potential to compromise residents' health and safety.Findings:Review of the facility's policy and procedure titled, Side Rail, indicated the last review and revision was 3/2018.During a concurrent interview with the director of staff development (DSD) and document review on 9/18/2025 at 10:09 a.m., the DSD reviewed the Side Rail policy and procedure and confirmed the last time it was reviewed was in 2018. The DSD stated they reviewed their policy and procedures yearly.During a concurrent interview with the interim director of nursing (IDON) and document review on 9/19/2025 at 1:38 p.m., the IDON reviewed the Side Rail policy and procedure and confirmed it was revised in 2018. IDON stated they have a Patient Care Policy Committee, and they meet annually to review or revise their policy and procedures. The IDON further stated their Side Rail policy and procedure should have been revised in 2024 and their plan moving forward was to review all their policy and procedures.During a review of the undated facility document titled, Continuous Quality Improvement Report, indicated, Patient Care Policy Committee . meets Annually . Topic discuss are the following: revisions, implement and review of Policy and Procedures, area of concerns, what action taken. Event ID: Facility ID: 055462 If continuation sheet Page 17 of 20 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 09/19/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. Registered nurse A (RN A) did not remove dirty gloves, perform hand hygiene (the act of cleaning hands with soap and water or an alcohol-based hand sanitizer to remove germs and prevent the spread of infections) and don (put on) a new pair of gloves before doing Resident 65's finger stick test (method of drawing drops of blood, most commonly used by people with high blood sugar to check their levels), and RN A did not perform hand hygiene after she picked the glove that fell on the floor and before putting on clean gloves prior to medication preparation;2. Registered nurse E (RN E) did not perform hand hygiene prior to medication administration;3. Certified nursing assistant C (CNA C) and licensed vocational nurse D (LVN D) did not perform hand hygiene in between assisting and feeding residents; and,4. Certified nursing assistant F (CNA F) did not change dirty gloves after Resident 12's toileting assistance, did not perform hand hygiene after removal of dirty gloves and before donning a new pair of gloves. These failures had the potential for the spread of infection and cross-contamination that could affect the eighty-nine residents residing in the facility, staff, and visitors. Residents Affected - Some Findings: 1a. During the medication pass observation with registered nurse A (RN A) on 9/16/25 at 11:25 a.m., RN A was preparing to check the blood sugar of Resident 65 using the finger stick test. RN A sanitized her hands and put on a pair of gloves. But before she did the finger stick test of Resident 65, RN A kept on moving the bedside table and placed it beside the bed. RN A proceeded to do the finger stick test of Resident 65 without changing gloves, sanitizing hands and putting on new gloves. 1b. During the continued medication pass observation with RN A on 9/16/25 at 11:30 a.m., RN A went back to the medication cart to prepare the Novolog (insulin aspart, rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes or high blood sugar) of Resident 65. RN A sanitized her hands and got a pair of gloves. She dropped one of the gloves on the floor and RN A picked it up with her sanitized hand and threw it in the garbage bin at the side of the medication cart. RN A then got another glove and put on the pair of gloves and proceeded to prepare the insulin aspart without sanitizing her hands first. During the interview with RN A on 9/16/25 at 3:15 p.m., RN A confirmed the above concerns. RN A further confirmed that she should not touch anything including, moving the bedside when she had already sanitized her hands and put on the gloves. RN A also confirmed that she should have sanitized her hands after she picked up the glove that fell on the floor and threw it in the garbage bin, before putting on a new pair of gloves. Review of Resident 65's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, she was admitted to the facility on [DATE] with the principal diagnosis (underlying cause of admission) of type 2 diabetes mellitus (adult onset high blood sugar levels) with other specified complications (unfavorable result of a health condition). Review of Resident 65's order summary report dated 9/15/25 indicated, Resident 65 had an order of Novolog FlexPen (pre-filled pen designed to administer insulin for the treatment of diabetes) subcutaneous (beneath, or under, all the layers of the skin) solution pen-injector 100 units (standards of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 18 of 20 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 09/19/2025 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 - Some measuring and expressing physical quantities)/ml (milliliter, unit of volume in the metric system), inject 3 units subcutaneously with meals and also as per sliding scale (dosing strategy for insulin where the amount administered is adjusted based on a person's current blood sugar level), for type 2 diabetes mellitus with other specified complications, ordered on 8/18/25. During the interview with the infection preventionist (IP) on 9/17/25 at 9:40 a.m., IP verified the above concerns. IP further verified that nurses should remove gloves, sanitize hands and put on new pair of gloves when she touched things or move bedside tables prior to doing finger stick tests. IP also verified that nurses should sanitize hands as well after picking up something from the floor, before putting on new pair of gloves. 2. During the concurrent medication pass observation and interview with RN E on 9/17/25 at 4:42 p.m., RN E, sanitized his hands, prepared the amlodipine besylate (used to treat high blood pressure or hypertension) 5 mg tablet of Resident 63 and then give it to Resident 63. But before giving the amlodipine, RN E moved the bedside table near the resident with his sanitized bare hands. He then proceeded to give the amlodipine besylate tablet without sanitizing his hands. RN E confirmed that he should have sanitized his hands first because he was touching and moving the table near the resident, before giving the medication of Resident 63. Review of Resident 63's admission record indicated, Resident 63 was admitted to the facility on [DATE] with the principal diagnosis of unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), unspecified severity with agitation (state of severe restlessness or inner tension). Review of Resident 63's order summary report dated 9/18/25 indicated, Resident 63 had an order of amlodipine besylate oral tablet, 5 milligrams (mg, unit of weight), give 1 tablet by mouth one time a day for essential primary hypertension (condition characterized by persistently elevated blood pressure without identifiable underlying cause). Hold if systolic blood pressure (SBP, pressure in the arteries when the heart beats and pumps blood throughout the body) was below 100 millimeters of mercury (mmHg, unit of pressure most commonly used to measure blood pressure). During the interview with the interim director of nursing (IDON) on 9/19/25 at 12:59 p.m., IDON verified all the above concerns. IDON further verified that the nurse should have removed gloves, sanitized hands and put on new gloves before she did the fingerstick test, because she was touching and moving the bedside table prior to the test and should have also sanitized her hands after picking up the glove that fell on the floor before putting on clean gloves. IDON also verified that nurses should sanitize hands as well before giving medication, when they are touching the bedside table with bare hands before medication administration. Review of the undated facility's policy and procedure titled Hand Hygiene, indicated, Hand hygiene is the single most important procedure in preventing the spread of infection. This is an organization-wide policy. It applies to all care settings and services . Hand washing and hand antisepsis indications . Before and after having direct patient care . Before and after preparing and administering medications . If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations . 3. During Dining Observation on 9/15/25 at 12:20 p.m. in the Dining Room, Certified Nurse Aide (CNA) C was feeding Resident 89. CNA C tapped Resident 89's dining scarf and then proceeded to another table and started assisting and feeding Resident 62. CNA C was observed touching Resident 62's hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 19 of 20 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 09/19/2025 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 - Some CNA C left the room and Licensed Vocational Nurse (LVN) D took over the feeding of Resident 62. LVN D was sitting in between Resident 62 and Resident 92. LVN D wiped Resident 92's mouth using Resident 92's dining scarf and did not do hand hygiene before proceeding to continue feeding Resident 62. LVN stated, hand hygiene was needed in between assisting two residents. During an interview on 9/15/25 at 12:48 p.m. with CNA C, CNA C stated hand hygiene should have been done prior to assisting Resident 62. A review of facility's Policy and Procedure (P&P) entitled Policy: Hand Hygiene revised 1/3/2022, the P&P indicated, .1.Hand Washing and hand antisepsis indications: a.Hand washing is necessary in, but not limited to, the following situations:.2.Before and after having direct patient care 3.Between direct patient care contacts with different patients.13.Before and after contact with patients intact skin. 4.During an observation on 9/15/2025 at 11:14 a.m., inside Resident 12's room, the following were observed: 4a. CNA F came out of Resident 12's bathroom and threw some garbage wearing a pair of gloves, then he wheeled out Resident 12 from the bathroom by touching the wheelchair's handles with the same pair of gloves, and positioned Resident 12 beside her bed; 4b. CNA F removed the dirty gloves, did not perform hand hygiene, touched Resident 12's drawer handle to open and grabbed a pair of socks from the drawer; 4c. CNA F donned a new pair of gloves, without hand hygiene, and assisted Resident 12 in putting on her socks; 4d. CNA F removed his gloves, did not perform hand hygiene, went out to the hallway, touched the linen cart with unsanitized (dirty and carry germs, bacteria, and other mircroorganisms that can spread illness) hands, grabbed a clean hand towel, and handed the clean hand towel to Resident 12. During an interview with CNA F on 9/15/2025 at 11:18 a.m., CNA F confirmed the above observations and apologized for not performing hand hygiene every time he changed his gloves. CNA F stated he should have changed his gloves after he threw some garbage and he should have sanitized his hands before donning and upon removal of gloves. CNA F confirmed Resident 12 had a bowel movement and he assisted her with toileting. During an interview with the IP on 9/17/2025 at 9:36 a.m., the IP stated staff should perform hand hygiene before donning a new pair of gloves and after removal of gloves. The IP further stated the staff should use hand sanitizer if their hands were not visibly soiled. During a review of the facility's undated policy and procedure titled, Hand Hygiene, indicated, Hand washing is necessary in, but not limited to, the following situations . Before donning gloves and after removing gloves . Before and after handling patient body fluids, excretions or mucus membranes. i.e., urine, feces, sputum, blood. Gloves shall be used in addition to hand washing, not a substitute for. Hand hygiene must be completed after each glove removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055462 If continuation sheet Page 20 of 20