Other·May 2, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 4/18/19. The facility was licensed for 119 beds. The census at the time of the survey was 95. The sample size was 19. For F689, the scope and severity was a "G". A Class "B" citation was also issued. For Complaint CA00631987, regarding Quality of Care/Treatment, the Department did not substantiate a violation of a federal or state regulation. For Facility Reported Incident CA00632676, regarding Quality of Care/Treatment, the Department did not substantiate a violation of a federal or state regulation. Representing the California Department of Public Health: 34383, Health Facilities Evaluator Nurse; 37883, Health Facilities Evaluator Supervisor; 35157, Health Facilities Evaluator Nurse; 38174, Health Facilities Evaluator Nurse; and 39588, Health Facilities Evaluator Nurse.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 05/12/2019 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 1 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure needs were accommodated for one of two sampled Residents (25) when the call light was not within reach to use. This failure had the potential to negatively affect the residents' safety and delay the care and services rendered to residents. Findings: During an observation on 4/18/19 at 9:36 a.m., Resident 25 was lying in bed and his call light was inside his bedside drawer. During an interview with certified nursing assistant H (CNA H) on 4/18/19 at 9:45 a.m., he confirmed the above observation. CNA H stated Resident 25 had a shower and he forgot to put the call light within Resident 25's reach. During another observation on 4/16/19 at 8:51 a.m., Resident 25 was lying in bed. Resident 25's call light was placed on top of his bedside table and his bedside table was situated close to his knees. Resident 25 was observed trying to reach the call light with his right arm, and his right arm was shaky. Resident 25 was not able to reach for his call light. During an observation and concurrent interview with licensed vocational nurse F (LVN F) on 4/16/19 at 8:56 a.m., he stated Resident 25 was capable of using his call light by "tapping on it". LVN F then moved the bedside table closer to Resident 25. LVN F stated the bedside table should be closer to Resident 25 so he could reach his call light. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 2 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 25's care plan dated 10/12/16, indicated to make sure Resident 25 call light was within reach and encouraged to use it for assistance as needed. Review of the facility's 5/2001 policy, "Call Bell", indicated every resident would have a call light within reach at all times.

F578 SS=C Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 05/12/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 3 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to inform and provide written information for six of six sampled residents (56, 78, 8, 86, 289, and 290) concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care, recognized under state law, relating to the provision of health care when the individual becomes incapacitated). This failure would deny the resident and or responsible party (RP) to make decisions regarding health care when he/she becomes incapacitated. Findings: 1. Review of Resident 56's clinical record on 4/16/19 indicated she was admitted on 10/2/15 with diagnoses to include seizure disorder, history of stroke, high cholesterol, diabetes, hypertension, chronic atrial fibrillation( irregular heart rate), and severe dementia among others. Review of Resident 56's POLST form indicated the AD section of the POLST was not completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 4 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the assistant director of nursing E (ADON E) on 4/16 at 10:15 a.m., she stated the admitting nurse would fill up the forms including the AD. The ADON stated social service would follow-up if the AD section was not completed. During an interview with the minimum data set coordinator 2 (MDSC 2) on 4/16/19 at 2:30 p.m., she stated the administrative assistant would initiate the POLST on admission. She acknowledged the AD was not completed and someone should have followed-up. The MDSC 2 also stated they would review the POLST and AD during the care conference meeting and, if the resident did not have an AD, the facility would help formulate one through social service. 2. Review of Resident 78's clinical record indicated she was admitted on 4/10/17 with diagnoses to include chronic hepatitis (liver disease), seizures, depression, high blood pressure, high cholesterol, gout (disease caused by abnormal uric acid) among others. Her code status (level of medical intervention a person wishes if their heart or breathing stops) was NO CPR (cardiopulmonary resuscitation, also known as do not resuscitate (DNR). Her POLST form did not include a section on AD. During an interview with registered nurse G (RN G) on 4/16/19 at 9:15 a.m., she looked at the form and stated that it was an old form and was not sure why it was used. When asked who was in charge of the AD, she stated the admission nurse was in charge of filling up the forms. 3. Review of Resident 8's clinical record on 4/16/19 indicated she was admitted on 5/22/18 for essential hypertension (high blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 5 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure). Her code status was NO CPR. Review of Resident 8's Physician Orders for Life-Sustaining Treatment form (POLST, a medical order for the specific treatment an individual wants in case of emergency) did not include an AD section. It was also an old form as stated earlier by RN G. Review of Residents 8, 56 and 78 recent care conferences dated 1/29/19, 3/12/19, and 3/6/19, indicated Advance Directives were not reviewed. 4. Review of Resident 86's clinical record indicated he was admitted on 3/21/19 for fracture of left humerus (the long bone in the upper arm). His code status was NO CPR. Review of Resident 86's POLST form indicated an incomplete AD section. 5. Review of Resident 289's clinical record indicated he was readmitted on 4/6/18 with diagnoses including hypertension. His code status was NO CPR. Review of Resident 289's POLST form indicated the AD section was not completed. 6. Review of Resident 290's clinical record indicated he was admitted to the facility on 4/7/19 with a diagnoses including acute left multiple rib fractures. Review of Resident 290's POLST form indicated the AD section was not completed. Review of Residents 86 and 289 recent care conference dated 3/26/19 and 2/12/19, indicated Advance Directives were not reviewed. During an interview with ADON E on 4/16/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 6 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10:09 a.m., she stated the admission nurse would fill up the POLST form and no one was assigned to follow up if there was a missing information. ADON E also stated they would discuss the AD during their care conference meeting. Review of the facility's policy dated 4/18, "Advance Directives", indicated... Each resident's medical record will contain written information of whether or not the resident has completed an Advance Directive... At the time of admission all resident and/or family representatives, will be provided with written information about California state law on Advance Directives and a copy of the policy and procedure.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 05/12/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement their policy and procedure for one of one sampled resident (Resident 59) when an allegation of abuse was not reported immediately to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 7 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE abuse coordinator to investigate the dark purplish skin discoloration on the left arm. This failure had the potential for continued abuse and harm to the residents. Findings: Review of Resident 59's face sheet indicated he had dementia (memory disorder), diabetes (increase blood sugar), and heart failure (a failure of the heart to function properly). His Minimum Data Set (MDS, an assessment tool) dated 3/5/19, indicated the resident could not make decision, required assistance for bed mobility, transfer, dressing, eating, toileting, personal hygiene, and bathing. During an observation on 4/15/19 at 12:22 p.m., Resident 59 was observed in dining area with a dark purplish skin discoloration on the left arm. During an interview with Resident 59 on 4/17/19 at 8:01 a.m., Resident 59 stated he did not know what happened to the dark purplish skin discoloration on his left arm. During an observation and interview with certified nurse assistant C (CNA C) on 4/17/19 at 8:27 a.m., CNA A stated during her shift on 4/16/19, she was assigned to Resident 59 and she observed the dark purplish skin discoloration on the resident's left arm. CNA C stated she did not know why the resident's left arm had an approximately two inches in length and two inches in width dark purplish skin discoloration. During an interview with registered nurse A (RN A) on 4/17/19 at 8:33 a.m., she stated she was the charge nurse on 4/16/19 and CNA C did not report the dark purplish skin discoloration on the left arm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 8 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with RN B on 4/17/19 at 8:38 a.m., RN B stated CNA C should have immediately reported the dark purplish skin discoloration on the left arm to the charge nurse and investigate what happened. RN B stated there was no evidence of documentation regarding the dark purplish skin discoloration in the clinical record. During an interview with the director of nursing (DON) on 4/17/19 at 9:43 a.m., she confirmed the dark purplish skin discoloration on the left arm was a bruise of unknown origin and should have been reported to the abuse coordinator. The DON also acknowledged the allegation of abuse policy and procedure was not followed regarding the incident. Review of the facility's 12/2011 policy, "Abuse, Elderly/Dependent Adult Identification/Injury of an Unknown Origin/Reporting/Response", indicated the abuse identification had following criteria and assist in identifying physical abuse such as bruise, scratches, cuts and welts. Report the allegation or suspected abuse and injury of unknown origin immediately to the abuse coordinator to initiate investigation.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 05/12/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 9 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record interview, the facility failed to develop, implement, and revise the care plan (provide direction for individualized care) for three of 19 sampled residents (Residents 60, 86, and 62). For Resident 60, the care plan for risk for bleeding and bruising was not implemented. For Resident 86, the fall care plan was not revise to reflect the accurate interventions. For Resident 62, care plan intervention to place Dycem (non-slip) pad was not followed. These FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 10 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE failures had the potential to result resident care needs and services not meeting their individual needs. Findings: 1. Review of Resident 60's face sheet indicated she was admitted on 10/23/13 with a diagnoses of diabetes (increase blood sugar), dementia (memory disorder), and chronic obstructive pulmonary disease (COPD, lung disease). Her Minimum Data Set (MDS, an assessment tool) dated 3/6/19, indicated she was cognitively intact, required assistance for bed mobility, transfer, dressing, eating, toileting, personal hygiene, and bathing. Review of Resident 60's physician order dated 6/23/17, indicated Plavix (anticoagulant medication) tablet 75 milligrams one tablet once a day for blood clot (gel-like clumps of blood). Review of Resident 60's risk for bleeding and bruising related to anticoagulant medication. The interventions was to inspect skin daily during care and observe for signs of bruising. During an observation with Resident 60 on 4/15/19 at 9:23 a.m., Resident was sleeping in her bed and observed bruise on right lower arm. During an interview with Resident 60 on 4/16/19 at 12:21 a.m., she stated she had a bruise on the right arm and got it last week related to her anticoagulant medication. During an interview with registered nurse B (RN B) on 4/17/19 at 9:10 a.m., she confirmed Resident 60 had bruise on right lower arm, approximately 5.5 centimeter (cm, unit of measurement) length and 1.5 cm in width. RN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 11 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE B stated there was no documentation regarding the bruise on right lower arm. During an interview with assistant director of nursing (ADON) on 4/18/19 at 8:11 a.m., she stated the care plan interventions for risk for bleeding and bruising was not implemented. She also stated the bruise was not inspected and observe during daily skin care. 2. Review of Resident 86's clinical record indicated he was admitted to the facility on 3/21/19 with a diagnoses including fracture of left humerus (the long bone in the upper arm). Resident 86 had a sling on his left arm at all times. Review of Resident 86's change of condition (COC) evaluation indicated on 3/27/19, in the morning, Resident 86 had a fall in his room. Certified Nursing Assistant I (CNA I) was transferring Resident 86 from his wheelchair to bed when Resident 86 legs gave out. CNA I assisted Resident 86 to the floor. Review of Resident 86's fall care plan dated 3/22/19 indicated assist with transfer/ambulation as needed and as required. Review of physical therapy (PT) 86's screening sheet dated 3/22/19 indicated the current care plan for mobility status and transfer with two person assist. The PT recommendations were maximum dependent for stand balance and transfer. During an interview with the physical therapist (PT) on 4/17/19 at 4:30 p.m., the PT confirmed Resident 86 required two persons assist during transfer based on his screening made on 3/21/19 and was communicated to nursing. During an interview with registered nurse G FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 12 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (RN G) on 4/17/19 at 4:44 p.m., she confirmed she initiated the care plan for Resident 86. RN G stated based on her interview with the licensed staffs, she documented 1-2 person during transfers for Resident 86. RN G said she did not "see" the PT screening. RN G stated she should revise the care plan to reflect the correct transfer assistance as recommended by the PT. 3. A review of Resident 62's admission record indicated, Resident 62 was originally admitted to the facility on 5/5/15 and with current diagnoses including fracture of the left femur (long bone of the leg), repeated falls, and dementia. A review of resident 62's current high risk for falls long term care plan, indicated intervention to place Dycem underneath and on top of wedge cushion. During an observation and concurrent interview with the Minimum Data Set Coordinator 1 (MDSC 1) on 4/17/19 at 5:10 p.m., Resident 62's wheelchair did not include a Dycem underneath the wedge cushion. MDSC 1 confirmed the above observation and stated Dycem needed to be underneath the cushion too. Review of the facility's 1/7/06 policy, "Care Plan", indicated each resident would have an individualized wriiten care plan to reflect his/her healthcare and nursing needs. The purpose of care paln was to provide communication between care-givers, directing care, documentation, providing a written record which used for evaluation.

F688 SS=D Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 05/12/2019 §483.25(c) Mobility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 13 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure appropriate treatment and services for one of six sampled residents (60) when the restorative nursing aide (RNA, program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) program had no weekly RNA notes in regards with the resident participation, resident response, and the goal of the RNA program. This failure had the potential not to meet the goal and address her needs. Findings: Review of Resident 60's face sheet indicated she was admitted on 10/23/13 with a diagnoses of diabetes (increase blood sugar), dementia (memory disorder), and chronic obstructive pulmonary disease (COPD, lung disease). Her Minimum Data Set (MDS, an assessment tool) dated 3/6/19, indicated she was cognitively FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 14 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intact, required assistance for bed mobility, transfer, dressing, eating, toileting, personal hygiene, bathing, and the functional limitation in range of motion (ROM, a measurement of movement around the joint) of upper extremity was impaired on one side. Review of Resident 60's restorative nursing program referral form dated 6/6/17, indicated Resident 60 had a muscle weakness, and right wrist pain. Resident 60's RNA goal was to maintain upper body, lower body strength, and range of motion. Resident 60's RNA treatment plan was for upper body cycle, leg exercises and squeeze small beach ball between knees for three times per week. Review of Resident 60's RNA weekly notes for 3/2019 and 4/2019, there was no RNA weekly notes regarding Resident 60's RNA goals, the resident participation, and the response to the RNA program. During an interview with certified nurse assistant D (CNA D) on 4/18/19 at 2:18 p.m., she confirmed she was the assigned RNA for Resident 60. CNA D stated there was no RNA weekly notes for Resident 60 if the resident met the goals, participated, and responded to the RNA program. During an interview with Minimum Data Set Coordinator 1 (MDSC 1) on 4/18/19 at 2:30 p.m., she stated the resident ROM was a RNA functional maintenance program and she confirmed there was no RNA weekly notes for Resident 60. She also stated Resident 60 should have RNA weekly notes to evaluate the effectiveness of the RNA program. Review of the facility's undated policy, "RNA Functional Maintenance Program", indicated the resident was assisted to maintain and keep FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 15 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the maximum potential. RNA weekly charting would include the goals, resident participation and the response to the program.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/12/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on The facility failed to prevent accidents for one resident (Resident 62) when staff did not provide supervision to prevent falls and did not develop, revise and/or implement resident centered care plan and interventions to prevent future falls for Resident 62. These failures resulted in Resident 62 falling 18 times and one fall resulted in a left hip fracture. Review of Resident 62's admission record indicated, Resident 62 was admitted to the facility on 5/5/15 with diagnoses including osteoarthritis (disease where the flexible tissue at the ends of bones wears down), osteoporosis (condition in which bones become weak and brittle), cataract (clouding of the normally clear lens of the eye) repeated falls, and dementia (decline in mental ability severe enough to interfere with daily life). Review of Resident 62's comprehensive Minimum Data Set (MDS, an assessment tool) dated 10/31/18, indicated she had a brief interview for mental status (BIMS) and scored 6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 16 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (a score of 0 -7 indicates severe cognitive impairment). Resident 62 required extensive assistance (staff to provided weight bearing support) with one-person physical assist on transfer from one surface to another (bed, chair, wheelchair), locomotion on unit, locomotion off unit, personal hygiene and toilet use. Resident 62's balance was not steady and she can only be stabilized with staff assistance for moving from seated to standing position, move on and off the toilet and surface to surface transfers. During an interview with the Minimum Data Set Coordinator 1 (MDSC 1) on 4/17/19 at 10:24 a.m., she stated the Bowel and Bladder Assessment dated 10/19/18, indicated bladder retraining was done January 2017, May 2017 and July 2017 with no improvement noted. No other evidence of bowel and bladder re-training programs were provided. The MDSC further stated Resident 62 was not on a toileting program. Review of Resident 62's Morse Fall Scale (method of assessing a patient's likelihood of falling) dated 11/16/18 scored 75, indicating a high risk for falling. The assessment further indicated Resident 62 exhibited impaired gait (cannot walk unassisted, difficulty rising from chair) and Resident 62 overestimates or forgets limits in ambulation (walk) safety. During an interview and concurrent record review of Resident 62's Interdisciplinary (IDT, staff from different disciplines who work to together to plan and provide care) Post Fall Review summary with the MDSC 1 on 4/17/18 at 4:23 p.m., she confirmed Resident 62 had 29 falls from 3/21/18 to 3/29/19. On 11/26/18, Resident 62 fell and broke her left hip, which was her 19th fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 17 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Reviews of several of Resident 62's Change of Condition (COC) Evaluations and Interdisciplinary Post Fall Reviews from 3/21/18 to 11/26/18 it indicated Resident 62 had fallen 19 times with scenarios such as attempting to go to the bathroom and transferring to and from the wheelchair or the sofa. Review of Resident 62's high risk for falls care plan, initiated on 10/10/16, indicated Resident 62 as high risk for falls related to gait and balance problems, psychoactive (medications capable of affecting the mind) drug use, history of falls, cognitive deficits, very forgetful due to diagnosis of dementia, risky/non-compliant behavior and impaired mobility, history of refusing use of auto lock on wheelchair and over estimates her ability to self-transfer or ambulate without assistance. Some interventions included to continue to remind, reeducate resident not to transfer unassisted, educate family to report any fall incidents and call staff for help, encourage and arrange with family to come and help with 1:1 (one to one) supervision, continue frequent rounds every 15 to 30 minutes, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. No evidence of monitoring for rounds or frequent visual checks were provided. During an interview with the MDSC 1 on 4/18/19 at 8:18 a.m., she stated frequent visual checks and care plan intervention of every 1 hour checks are not being documented and monitored. Review of Resident 62's IDT Post Fall Reviews from 3/21/18 to 11/26/18, indicated Resident 62 had fell 19 times and 11 of those falls were unwitnessed. During an interview and concurrent record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 18 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review Resident 62's post fall care plans with the MDSC 1 on 4/17/18 at 1:20 p.m., she indicated the IDT team conducted a review on each fall and developed care plan interventions appropriate for the fall incident. She confirmed there were no new interventions put in place for Resident 62's falls on 3/29/18, 7/20/18, and 9/26/18. Review of Resident 62's IDT post fall review dated 11/26/18, indicated staff heard someone shouting for help in Resident 62's room and found her on the floor and the resident's left leg was lying over her right lower extremity. Resident 62 complained of severe pain on her left leg, It further indicated Resident 62 had poor safety awareness and was non-complaint with safety and did not ask for assistance when needed and the root cause of the fall was her impulsivity. During an interview with the DON on 4/17/18 at 4:07 p.m., she stated on 11/26/18 at 6:05 a.m. and 6:15 a.m., Resident 62 was in bed sleeping, then on 6:40 a.m. a certified nursing assistant (CNA) and a licensed vocational nurse (LVN) heard a noise from Resident 62's bedroom and found the resident lying on the floor. The DON further stated the root cause of Resident 62's fall was because of her noncompliance with safety and transfers without calling for assistance. Review of Resident 62's X-ray (photographic or digital image of a part of the body report) dated 11/26/18, indicated Resident 62 had a displaced left intertrochanteric fracture (hip fracture located at the bony protrusions on the thighbone). During an interview with LVN L on 4/18/19 at 9:19 a.m., he indicated Resident 62 had an unwitnessed fall on 11/26/18 at around 6:40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 19 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m. Resident 62 was found lying on the floor in her room near the bathroom door. Resident 62 complained of severe pain on her leg and was sent to the emergency room (ER). During an interview with LVN L on 4/18/19 at 11:44 a.m., he indicated Resident 62 needed extensive assistance in toileting and transfers. He further stated Resident 62 needed supervision at all times due to her confusion. During an interview with physical therapist J (PT J) on 4/18/19 at 12:22 p.m., she indicated Resident 62 needed supervision from staff for surface to surface transfers. Resident 62 was not capable of motor planning (ability to conceive, plan, and carry out movement and coordination of the arms, legs, and other large body parts from beginning to end). PT J further stated Resident 62's behavior was very unpredictable and unsafe. During an interview with the LVN K on 4/18/19 at 2:30 p.m., he stated Resident 62 was not able to safely transfer herself and needed assistance for transfers. He further stated "we need to keep an eye" on Resident 62, and she should always be in staff's line of sight. Review of the facility policy, "Care Plan - How to write" dated 1/7/06, 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 policy further stipulated "the care plan must have resident centered expected outcomes (goals, objectives) ... outcomes should be specific and measurable." Review of the facility policy, "Fall Prevention and risk reduction dated 4/15 indicated "Based upon total score of the fall risk evaluation, a comprehensive plan of care will be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 20 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE implemented to prevent resident's fall when it is preventable and minimize fall resulted injuries as much as possible."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/12/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to sufficiently label medications and supplements for 6 residents (20, 25, 43, 63, 68, and 78). This failure had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 21 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the potential to result in the accidental administration of the wrong medication or supplement to the wrong resident. Findings: During a medication pass observation at facility A on 4/16/19 at 4:39 p.m., with registered nurse D (RN D), three open bottles of house supplied polyvinyl alcohol 1.4 percent ophthalmic solution (eye drops) were in the medication cart labeled with only the room number of the resident for whom the medication was prescribed for 3 residents (25, 68, and 78). During a concurrent interview, RN C confirmed the observation. During a subsequent interview on 4/16/19 at 4:55 p.m., with the Director of Nurses (DON), she confirmed that the three boxes of house supplied eye drops in the medication cart were labeled with only the resident room number stating that this is the "facility's practice." During a medication cart inspection at facility B on 4/17/19 at 10:40 a.m., with RN B, a bottle of Alfalfa (supplement) 500 mg for Resident 43 was in the medication cart labeled with only the last name of the resident. A bottle of Cranberry Benefits (supplement) for Resident 20 was in the medication cart labeled with only the room number of the resident. A bottle of Magnesium (supplement) 250 mg was in the medication cart labeled with only the room number of a resident who had been discharged from the facility. Resident 63 was occupying the room associated with Magnesium 250 mg for which he had no order. During a concurrent interview, RN B confirmed the observation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 22 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a subsequent interview and clinical record review with the Assistant Director of Nurses (ADON) on 4/17/19 at 4:32 p.m., she confirmed there was no current order for Magnesium 250 mg for Resident 63. The ADON stated the supplement was "probably [sic] the previous patient". A review of the facility's policy, "Medication Policy" dated 02/96, indicated "All of the resident's medications will be labeled with the resident's name, physician, strength of medication, dose and method of administration, and expiration date."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 05/12/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to store, prepare, and distribute food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 23 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE safely when at facility A: 1. a radio covered with particulate was on the center island near clean cutting boards 2. a red bucket of Quaternary Ammonium (QUAT, a sanitizer) was in the sink near a pan of cauliflower 3. a green bucket of detergent and a white bucket of QUAT solution were next to plastic utensils 4. a pan of cornbread was on top of the ice machine next to the three compartment sink 5. a pan of cookies was on top of the ice machine next to the three compartment sink at facility B: 6. a radio covered with particulate was on the clean side of the sink 7. a red bucket of QUAT solution was on the clean grill 8. freezer #2 had hot dogs, muffins, and tortillas with freezer burn These failures had the potential to cause food borne illness to a highly susceptible population of 94 residents who received food from the kitchen. Findings: During an initial tour and observation of facility B's kitchen on 4/15/19 at 8:05 a.m. with the Certified Dietary Manager (CDM), a radio covered with particulate was on the clean side of the sink; a red bucket of QUAT solution was on the clean grill; and freezer #2 had three bags of hot dogs, six muffins, and one package tortillas with freezer burn. During a concurrent interview with the CDM, she confirmed the observations. When asked if the QUAT should be on the grill, the CDM stated "no". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 24 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an initial tour and observation of facility A kitchen on 4/15/19 at 9:08 a.m. with the Registered Dietician (RD), a radio covered with particulate was on the center island near clean cutting boards; a red bucket of QUAT was in the sink near a pan of cauliflower; and a pan of cornbread was on top of the ice machine next to the three compartment sink. During a concurrent interview, the RD confirmed the observations. When asked if the cauliflower should be near the QUAT, the RD responded "no". When asked if the cornbread should be on top of the ice machine, the RD responded "no". During a subsequent observation of facility A kitchen on 4/16/19 at 9:21 a.m. with the CDM, a green bucket of detergent and a white bucket of QUAT solution were next to plastic utensils; and a pan of cookies was on top of the ice machine next to the three compartment sink. During a concurrent interview with the CDM, she confirmed the observations. When asked if the plastic utensils should be near the detergent and QUAT, the CDM responded "it shouldn't be". A review of the facility's policy, "Infection Control: Food Receiving & Storage" dated 1/02, indicated "All cleaning agents, chemicals, and other hazardous items are to be stored in a separate area, away from food products." The USDA Food Code, 2017, section 3-305.11, states "... FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor."

F867 QAPI/QAA Improvement Activities FORM CMS-2567(02-99) Previous Versions Obsolete

F867 Event ID: 9ID511 05/12/2019 Facility ID: CA070000426 If continuation sheet 25 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.75(g)(2)(ii) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to: 1. Develop and implement formal corrective action plans to address an increase in the number of resident falls. 2. Develop and implement formal corrective action plans to address an increase in the number of residents with weight loss. These failures resulted in an ineffective QAPI program to improve quality of care for all residents in the facility. Findings: During a review of the QAPI program on 4/18/19 at 1:28 p.m. with the Director of Nursing (DON), the April 2019 QAPI meeting data indicated resident falls increased from three in January to six in March (an increase of 50%); and the residents with weight loss increased from one in January to five in March (an increase of 80%). In a concurrent interview, the DON confirmed the data. When asked what current Performance Improvement Projects (PIPs) the QAPI committee was working on, the DON stated there were no current corrective actions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 26 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055462 (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF 911 Sunset Dr Hollister, CA 95023 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "We didn't identify any concerns." When asked if there were any PIPs from the previous QAPI meeting in January 2019, the DON stated "I don't think so." A review of the facility's undated policy, "Continuous Quality Improvement Report", indicated "The QAPI framework is established through five elements. Each element describes an important component of QAPI, and all elements are interconnected. Element 1 Design and Scope; Element 2 - Governance and Leadership; Element 3 - Feedback, Data Systems and Monitoring; Element 4 Performance Improvement Projects (PIPs); and Element 5 - Systematic analysis and Systemic Action." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ID511 Facility ID: CA070000426 If continuation sheet 27 of 27