Other·September 13, 2018

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 the CONCURRENT RECERTIFICATION and RELICENSING surveys and an ABBREVIATED survey to investigate COMPLAINT No. CA00595012. Representing the California Department of Public Health: Surveyor 38492, HFEN; Surveyor 32179, HFEN; Surveyor 38660, HFEN; Surveyor 35346, HFEN; Surveyor 33434, HFEN; Surveyor 40672, HFEN; and Surveyor 39683, HFEN. For COMPLAINT No. CA00595012: THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATION(S) AND FINDINGS WERE CITED AT F550. The surveyors entered the facility on 7/24/18 at 0730 hours. The census was 152. GLOSSARY OF ABBREVIATIONS: ADL - activities of daily living BNP - B-type natriueretic peptide (a hormone released primarily in the heart in response to circulatory volume overload and stretching of the ventricles of the heart) CDC - Centers for Disease Control and Prevention CHF - congestive heart failure (heart is unable to pump enough blood to maintain the needs of the body) CNA - Certified Nursing Assistant Contracture - a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints dialysis/hemodialysis - a treatment for removing waste and excess water from the 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: 4F9W11 Facility ID: CA060000094 If continuation sheet 1 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 blood due to failing kidney function DON - Director of Nursing I&O - intake and output LVN - Licensed Vocational Nurse MAR - Medication Administration Record MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) ml - milliliter(s) P&P - policy and procedure pg/ml - picogram(s) per milliliter PRN - as needed PROM - Passive Range of Motion RD - Registered Dietician RN - Registered Nurse RNA - Restorative Nursing Aide

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 2 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to show respect and dignity to the residents by not answering call lights in a timely manner for three of 30 final sampled residents (Residents 452, 40, and 10 ) and two of four nonsampled residents (Residents 15 and 105). This failure deprived the residents from receiving needed care and assistance in a dignified and timely manner. Findings: Review of the facility's Resident Council Minutes dated 4/5, 4/19, 5/3, 5/22, 6/5, 6/19, and 7/3/18, showed the residents' concerns with call lights not being answered in a timely manner. 1. On 7/24/18 at 1125 hours, an interview was conducted with Resident 452. Resident 452 stated at least two days since her admission to the facility, she had to wait over an hour after activating her call light so she could use the bathroom. The delay caused her to go in her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 3 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 brief and she became wet, which made her unhappy. On 7/27/18 at 1340 hours, a second interview was conducted with Resident 452. Resident 452 stated it was taking staff 1-1/2 hours to answer her call light as she needed something for her cough. The nurse answering the call light stated she would be back, but after a 1/2 hour, Resident 452 had to reactivate her call light and it was another 1/2 hour before a nurse answered to give her the cough medication. Resident 452 stated this made her feel she was not important. 2. On 7/31/18 at 1037 hours, an interview was conducted with Resident 15 about concerns brought up during the resident group interview held on 7/24/18 at 1400 hours. Resident 15 stated it took up to 2 hours according to the clock to answer her call light. Resident 15 stated she needed her brief changed or more water or was having difficulties with the television. Resident 15 stated the time of day or the day of the week did not matter for how long the call lights went unanswered. Resident 15 stated she got mad and felt the staff did not care about her when they took a long time to answer her call light. Resident 15 stated she became frustrated with the slow response to the call lights and this had been brought up many times during the resident council meetings. 3. On 7/27/18 at 0952 hours, an interview was conducted with Resident 105 about concerns brought up during the resident group interview held on 7/24/15 at 1400 hours. Resident 105 stated at least once a week, they had to wait 45 minutes or longer to have her wet brief changed. Resident 105 stated she did not know when she had to urinate but did know when she was wet. Resident 105 stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 4 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 felt uncomfortable and ignored when she had to wait so long to have her brief changed. Resident 105 stated it did not seem to matter if the Administrator attended the resident council meetings or not as things just did not get done. 4. On 7/25/18 at 0934 hours, an interview was conducted with the family of Resident 10. The family of Resident 10 expressed concern with call light not being answered timely. When the call light was activated, the response time was 45 minutes to 1 hour. The family member stated they called for Resident 10 because the resident was incontinent of urine and needed to urinate. The family member stated they needed to go out into the hallway to get help for Resident 10. The family member stated they also informed the staff before they left to help with changing the resident. The family member stated they had mentioned the concern to the Administrator in April 2018. On 8/1/18 at 1100 hours, an interview was conducted with the DON and Administrator. The Administrator stated she did not remember if the family member had talked to her about the call light and incontinence incidents. 5. On 7/24/18 at 813 hours, an interview was conducted with Resident 40. Resident 40 stated she depended on staff to help her transfer to her commode (portable toilet). Resident 40 stated when she activated her call light, CNA staff said they would return but did not reappear for one hour. Resident 40 stated the last time this happened was 7/23/18, before lunch when Resident 40's disposable underwear was soiled with urine.

F585 Grievances FORM CMS-2567(02-99) Previous Versions Obsolete

F585 Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 5 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.10(j)(1)-(4) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 6 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 7 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate and document the complaint/concern investigation and follow up with the resident per the facility's P&P for one of 30 final sampled residents (Resident 133). This failure had the potential to impact Resident 133's well-being and the risk of violating the resident's rights. Findings: Review of facility's P&P titled Grievance/Concern dated 3/1/18, showed the department manager will contact the person filing the grievance to acknowledge receipt, investigate the grievance, take corrective actions as needed, engage the support of the ombudsman if warranted and notify the person filing the grievance of resolution within 72 hours. Provide written resolution for Civil Rights grievances and, upon request for all other grievances, by giving a copy of the Grievance or Concern Form to the resident/resident representative. Medical record review for Resident 133 was initiated on 7/24/18. Resident 133 was admitted to the facility on 12/29/17. Review of Resident 133's History and Physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 8 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 Examination dated 3/21/18, showed Resident 133 had the capacity to understand and make decisions. Review of the Concern Form dated 7/13/18, showed Resident 133 had a concern about not receiving her 2000 hours medication: iron, gabapentin, MS Contin, Lantus, Dilaudid and her accucheck (blood sugar level) until 0200 hours. Under Recommended Corrective Action: showed, "The concerned LVN was inserviced on giving medication on time, however she left and is no longer (working) with us." On 7/30/18 at 1509 hours, an interview was conducted with Resident 133. Resident 133 stated two weeks ago she had filed a grievance because she she was not given her routine medication, including pain medication and the accucheck, which was scheduled for 1600 hours and 2000 hours, until 0200 hours. The nurse told Resident 133 she had 40 residents and was trying to get caught up. Resident 133 stated the nurse went to Resident 1's room and was preparing to administer an injection while Resident 1 was hanging in the air in a mechanical lift. Resident 133 stated she stopped the nurse from administering the medication. Both incidents happened with the same nurse on the 3 to 11 shift. Resident 133 stated her grievance was not followed up. Resident 133 stated she had a new concern about her call light being turned off four times by the staff without attending to her needs. On 7/30/18 at 1530 hours, an interview and concurrent medical record review was conducted with RN 1 and the DON. RN 1 and the DON was asked if Resident 133 had filed a grievance two weeks ago regarding medication administration. RN 1 and the DON stated they spoke with LVN 6 and LVN 6 was given an inFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 9 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 service. LVN 6 resigned. RN 1 stated the DON checked the Medication Administration Records and verified the medications were administered later, around midnight or 0200 hours. The blood sugar was not checked that night. LVN 6 told her they were short staffed. Cross reference to F755, example #1. On 7/30/18 at 1600 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked to show if the nurse had informed the physician and assessed the resident after the medication and blood sugar was checked late. The DON stated she was unable to locate the documentation. The DON was asked to show any documentation of the investigation with LVN 6 and other staff. The DON stated she was unable to show the documentation. The DON and RN 1 only interviewed LVN 6 and the resident. The DON stated she did not have the chance to speak with LVN 6 because was no longer working at the facility. The DON was asked if this incident affected others. The DON stated everyone got their medication on time when she checked the Medication Administration Records. On 7/30/18 at 1610 hours, an interview was conducted with RN 1. RN 1 was asked if Resident 133 was informed of the resolution to her grievance filed on 7/13/18. RN 1 did not respond. On 7/31/18 at 0940 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked if Resident 133's blood sugar was checked and if the insulin was given at 0200 hours. The DON stated yes. The DON was asked if she could show any documentation the routine medication (3 to 11 shift) was given around midnight to 0200 hours and if the blood sugar FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 10 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 was checked and insulin was given around 0200 hours. The DON was unable to show documentation. The DON stated LVN 3 was not savvy with the computer program; they sent her to computer classes. The DON stated Resident 133 told her LVN 6 had 40 residents. On 7/31/18 at 1400 hours, an interview and concurrent medical record review conducted with the DON. The DON was asked if she provided a resolution to Resident 133 and could show any documentation of the resolution to Resident 133. The DON stated she did not have a chance yet. The DON was asked to show any documentation if LVN 6 was given in-service about medication administration and the computer. The DON stated she was unable to show any documentation.

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 11 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 30 final sampled residents (Resident 10) was free from a physical restraint. The facility to ensure the least restrictive measures were attempted, the assessment was completed, and the informed consent was obtained from the resident prior to the use of an alarm and bolsters (a pillow type bumper used to prevent residents from easily getting out of bed). These failures resulted in compromising Resident 10's independence and psychological well-being. Findings: Review of the facility's P&P titled Restraints: Use of dated 7/1/18, showed bed rails and position change alarms may be considered restraints. Types of position changing alarms include chair and bed sensor pads, bedside alarm mats, alarms clipped to a patient's clothing, seatbelt alarm and infrared beam motion detectors. When the use of a restraint is indicated, the Center must use the least restrictive alternative for the least amount of time and document ongoing reevaluation of the need for restraints. Patients will be evaluated for the use of the restraint or protective device FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 12 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 the nursing assessment process. If it is determined that a protective device is being used as an enabler, no further assessment is needed. Consents must be obtained prior to applications of the restraint. On 7/26/18 at 0825 and 1130 hours, Resident 10 was observed in bed, awake. Bilateral bolsters were observed positioned from Resident 10's arm to the upper leg, creating a concave like mattress, inhibiting Resident 10 from freely abducting (the movement of a limb away from the midline of the body) his upper and lower extremities. A bed alarm was observed applied to the resident. Medical record review was initiated for Resident 10 on 2/27/18. Resident 10 was admitted to the facility on 2/1/16. Review of the History and Physical Examination dated 12/21/17, showed Resident 10 did not have the capacity to understand and make decisions. Review of Resident 10's plan of care showed a care plan problem dated 5/21/18, to address the resident was at risk for falls due to a history of falls, impaired balance, on hypertension and antianxiety medications and had a history of falls. The interventions included a low bed with floor mat when in bed, pad alarm while in bed, Tab alarm in wheelchair to alert staff of the resident getting up by herself, give assurance and support when having fear of falling. On 7/27/18 at 1010 hours, an interview was conducted with CNA 7 regarding Resident 10. CNA 7 stated Resident 10 was able to move his extremities on his own. CNA 7 stated Resident 10 required extensive assistance for turning and repositioning but the resident was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 13 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 able to move her body to the side and tried to get out of the bed. CNA 7 stated the bolster and bed alarm were to prevent the resident from falling. CNA 7 stated a month ago, Resident 10 tried to get up on her own to her bedside commode. CNA 7 stated Resident 10 could stand up, was ambulatory and needed one person's assistance to use the restroom. CNA 7 stated when the resident move or tried to get out of bed, the alarm sounded. On 7/27/18 at 1032 hours, an interview and concurrent observation was conducted with LVN 7 while at Resident 10's bedside. LVN 7 acknowledged the bolster could restrict Resident 10 from rolling out of the bed. The bed alarm sounded when the resident sometimes tried to get out of the bed. LVN 7 was asked to show documentation if the care plan problem was developed to address the use of a bolster, the least restrictive measure were attempted, the assessment and reevaluation was completed, the consent was obtained for the use of bolsters and an alarm. LVN 7 was unable to show the documentation. On 7/27/18 at 1533 hours, a concurrent interview and medical record review was conducted with the DON. The DON was asked if the fall risk assessment addressed the use of an alarm and bolsters and if any less restrictive measures were attempted, the DON acknowledged the assessment did not show the use of an alarm and bolsters. The DON verified the findings.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 14 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 15 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 16 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure a transfer/discharge notice was communicated or sent to the State Long Term Care Ombudsman as soon as practicable and a copy was given to the resident or their representative for one of three closed record sampled residents (Resident 152). This posed the risk of the Ombudsman not being aware of the circumstances should an appeal be filed by the resident or their representative regarding the transfer/discharge and the risk of the resident or their representative not being aware of their rights prior to the transfer/discharge from the facility. Findings: Medical record review was initiated for Resident 152 on 7/30/18. Resident 152 was admitted to the facility on 4/10/18, and discharged from the facility on 4/25/18. Review of the Discharge Summary/Comprehensive Assessment showed it was completed on 4/25/18. Review of the physician's order dated 4/18/18, showed to discharge Resident 152 on 4/25/18. Review of the Physician's Discharge Summary dated 5/29/18, showed the resident's health had improved and the resident was discharged to a board and care facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 17 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 the medical record failed to show a copy of the discharge/transfer notice. On 7/30/18 at 1530 hours, an interview and concurrent medical record review was conducted with the Medical Records Director concerning Resident 152. The Medical Records Director was asked who was responsible for the notification of the Ombudsman for the residents who were transferred/discharged. The Medical Records Director stated the facility social services staff or nursing staff was responsible for the notification of the Ombudsman of the transfers and discharges. The Medical Records Director was unable to locate a copy of the Notice of Discharge/Transfer in Resident 152's medical record. The Medical Records Director stated a copy should be in the medical record to show the resident and or family were notified and given a copy prior to discharge.

F640 SS=B Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 18 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to electronically transmit a resident assessment to CMS for one of 30 final sampled residents (Resident 1). This failure caused a delay in providing resident specific information for payment and quality measure purposes to CMS. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 19 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 Findings: Medical record review for Resident 1 was initiated on 7/24/18. Resident 1 was readmitted to the facility on 7/21/18. Review of resident 1's MDSs showed a quarterly MDS dated 5/9/18. The transmittal history for the MDS showed it was transmitted and accepted on 7/24/18. On 7/25/18 at 1420 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 2. MDS Coordinator 2 stated Resident 1's MDS dated 5/9/18, was accidentally locked as "Submit Req: Do not submit" and did not automatically get transmitted upon completion. MDS Coordinator 2 stated they did not routinely go back to ensure the MDSs were transmitted timely and per regulations. MDS Coordinator 2 stated the error was brought to the MDS staff's attention on 7/24/18, when an email from the corporate identified the transmittal as incomplete. The MDS was then unlocked and transmitted to CMS by the facility.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) §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 attain or maintain the resident's highest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 20 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 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 medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 30 final sampled residents (Resident 57). Resident 57's care plan did not address the resident's contracture, splint use and PROM. This failure had the risk of staff not providing appropriate, consistent, and individualized care to the resident. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 21 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 Medical record review for Resident 57 was initiated on 7/24/18. Resident 57 was readmitted to the facility on 4/24/17. Resident 57's History and Physical Examination dated 2/9/18, showed the resident had a right upper extremity contracture. Review of a physician's order dated 2/22/18, showed RNA splint program, right hand splint seven days a week for 4-6 hours, and for the RNA to perform the PROM exercises to both upper extremities seven days a week. Review of Resident 57's care plan did not address resident 57's contracture and RNA therapy and staff interventions. On 7/25/18 at 1348 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 57 was in the RNA splint program and received the PROM exercises seven days a week. LVN 1 stated Resident 57 had a contracture of his right upper extremity and muscle wasting and atrophy. LVN 1 reviewed the resident's care plan and stated it did not address the resident's contracture, splint use, and PROM exercises as part of the RNA program. On 8/1/18 at 0835 hours, an interview was conducted with MDS Coordinator 1. MDS coordinator 1 stated the care plan problems regarding RNA therapy should be completed by nursing staff. On 8/1/18 at 0846 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated the nurses were responsible for initiating and updating the care plan for RNA services.

F657 Care Plan Timing and Revision FORM CMS-2567(02-99) Previous Versions Obsolete

F657 Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 22 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.21(b)(2)(i)-(iii) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: 3. Medical record review for Resident 48 was initiated on 4/24/18. Resident 48 was readmitted to the facility on 12/25/17. Resident 48 had a physician's order dated 7/5/18, for the bilateral mats on the floor and a low bed. Review of Resident 48's care plan showed a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 23 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 care plan problem addressing the falls which had occurred on 12/26/17, 10/8/17, 3/11/18, and 5/19/18. The care plan nursing interventions included to place the floor mats on both sides of the bed and an alarm when in the bed/wheelchair. On 7/24/18 at 1020 hours, a concurrent observation and interview was conducted with Resident 48. Resident 48's bed was observed in the low position. Resident 48 stated she had falls in the past and got up when she wanted to use her walker. On 7/25/18 at 1354 hours, Resident 48 was observed lying in bed with their eyes closed. The bed was in the low position and no floor mats were in place. On 7/31/18 at 1351 hours, Resident 48 was observed lying in bed with the bed in the low position and a walker next to the bed. There were no floor mats located on either side of the resident's bed. On 7/31/18 at 1353 hours, an interview was conducted with Resident 48's assigned CNA, CNA 1. CNA 1 stated they had been taking care of Resident 48 over the past 3-4 months and were not aware the resident had any falls. When asked if Resident 48 had fall interventions in place, CNA 1 stated the resident did not need any floor mats. Upon observing the resident in her bed, CNA 1 verified the resident's bed was in the low position and no floor mats were in place. On 7/31/18 at 1358 hours, a concurrent interview and medical record review was conducted with Resident 48's nurse, LVN 1. LVN 1 stated the resident had falls in the past, but did not have an order for a low bed or floor mats. Upon observing the resident, LVN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 24 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 stated Resident 48's bed was currently in the low position since she was sleeping and verified there were no floor mats in place. LVN 1 stated when Resident 48 was awake, the bed was elevated so the resident could get out of bed on their own using the walker. LVN 1 reviewed Resident 48's physician's orders and stated there was an order for floor mats and for the bed to be in the low position. While reviewing the resident's care plan, the nurse stated the resident no longer had an alarm while in bed and did not use a wheelchair for alarm use. On 7/31/18 at 1546 hours, an interview was conducted with the DON. The DON stated on 7/5/18, during room rounds, she saw the resident did not have floor mats in place. She stated they were needed and were care planned as a fall intervention so she obtained an order to reinstate the floor mats. In a follow up interview, the DON stated the nurses are responsible for updating resident care plans. Cross reference to F689. 4. Medical record review for Resident 147 was initiated on 7/24/18. Resident 147 was admitted to the facility on 1/7/18. Review of the Order Summary Report dated 6/27/18, showed physician's orders for Resident 147 dated 5/11/18, for a bed alarm pad and bilateral bolster pillows on the bed. Review of Resident 147's fall risk care plan problem showed to utilize a low bed and bilateral full side rails. The care plan did not reflect the side rails were no longer in use and failed to show the bolster pillows and a bed alarm were in use for fall interventions. On 7/25/18 at 0826 hours, Resident 147 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 25 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 observed in bed with bilateral bolster pillows placed on each side of the bed. On 7/27/18 at 0915 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 147 was able to get his leg off of the bed but was not sure why the resident had the bolster pillows. CNA 8 verified a pad alarm was in use and stated it was needed in case the resident got out of bed. CNA 8 was not aware if Resident 147 had a fall while at the facility. On 7/27/18 at 1100 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the facility used the bolster pillows to keep Resident 147 in bed and prevent him from falling out of bed. RN 1 verified Resident 147's care plan did not address the bed alarm and bolster pillow use. On 7/27/18 at 1125 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the bed alarm and bolster pillow use should be addressed in the care plan. Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plans were developed and revised for four of 30 final sampled residents (Residents 10, 48, 90, and 147) to reflect changes in the residents' care needs. * The facility failed to update Resident 10's care plan to address the bowel and bladder concern. * The facility failed to revise the care plan for Resident 90 to address the interventions for the bilateral lower extremities' ROM fuctional limitation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 26 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 facility failed to revise Resident 48's fall care plan to ensure it reflected the resident's current physician's orders for the bilateral mats on the floor. * The facility failed to revise Resident 147's fall intervention care plan to ensure it reflected the resident's current physician's orders. These failures placed the residents at risk of their care needs not being met. Findings: 1. Medical record review for Resident 10 was initiated on 7/27/18. Resident 10 was admitted to the facility on 2/1/16. Review of Resident 10's care plan showed a care plan problem dated 5/21/18, addressing Resident 10's urinary and bowel incontinence. The interventions included to continue with the toileting schedule plan. On 7/27/18 at 1010 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 10 was not on a toileting schedule. CNA 7 stated Resident 10 was confused. On 7/27/18 at 1403 hours, an interview and concurrent medical record review was conducted for Resident 10 with RN 1. RN 1 stated Resident 10 was not on a toileting schedule because of cognitive issues. RN 1 acknowledged the care plan was not updated. RN 1 verified the findings. 2. Review of Resident 90's Physician and Telephone Orders showed an order dated 6/20/16, for Restorative Nursing Assistant for the PROM exercises to the bilateral lower extremities every day five days per week. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 27 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 90's care plan showed a care plan problem dated 6/29/17, to address the resident's requirement for extensive assistance for ADL care, specifically bathing, grooming, personal hygiene, dressing, eating, bed mobility, locomotion, toileting, and transfers related to confusion, paraplegia. However, the care plan failed to show any interventions to address the PROM exercises were needed to be provided to the resident. Review of Restorative Nursing Referral dated 6/30/16, showed the right lower and left lower extremity PROM exercises were provided every day, fives days per week. Review of Restorative Nursing Record for July 2018 showed Resident 90 had RNA services for PROM exercises to the bilateral lower extremities. On 7/26/18 at 0923 hours, an interview and concurrent review of Resident 90's care plan was initiated with MDS Coordinator 1. MDS Coordinator 1 was asked to show the care plan addressing the PROM exercises provided to Resident 90. MDS Coordinator 1 acknowledged the care plan problem did not show specific PROM exercises provided for Resident. MDS Coordinator 1 verified the finding.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 28 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 30 final sampled residents (Resident 96) had ongoing activities to meet the resident's interests and support the physical, mental, and psychosocial well-being of the resident. Findings: Medical record review for Resident 96 was initiated on 7/24/18. Resident 96 was admitted to the facility on 10/9/06. Resident 96 had severe cognitive impairment. Review of Resident 96's Recreation Service Participation Record Individual Engagement for February through July 2018 showed the following: * February 11-17: one room visit * February 18-24: two room visits * February 25- March 3: one room visit * March 4-10: two room visits * March 11-17: one room visit * March 18-24: one room visit (plus one attempt but resident was documented as sleeping) * March 25-31: no room visits (plus one attempt but resident was documented as sleeping) * April 8-14: two room visits * April 15-21: two room visits * May 6-12: two room visits * June 3-8: two room visits * June 10-16: two room visits (with one attempt where resident was documented as unavailable) * June 17-23: two room visits * June 24-30: two room visits FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 29 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 * July 8-14: two room visits On 7/24/18 at 0815 hours, Resident 96 was observed sitting in the corner of his room watching TV. On 7/24/18 at 1051 hours, Resident 96 was observed sleeping in a wheelchair in the corner of room. His bed was made and a CD player was located on the bed. The resident woke up, and when spoken to, he giggled. When asked if he attended any activities in the facility, he stated not today but would go tomorrow at his house. Resident 96 was observed alone in his room with the TV on at the following times: on 7/24/18 at 1525 hours, 7/25/18 at 1021 hours, 7/25/18 at 1418 hours, 7/26/18 at 1103 hours, 7/30/18 at 0958 hours, and 7/31/18 at 0839 hours. On 7/26/18 at 0923 hours, an interview and concurrent medical record review was conducted with the Recreation Director. The Recreation Director stated Resident 96 did not like group activities and was currently receiving room visits two to three times a week. She stated Resident 96 did not leave the facility for outside activities or community programs. While reviewing Resident 96's Recreation Service Participation Record Individual Engagement documentation for February - July 2018, the Recreation Director stated in April 2018, she noticed there were weeks in February and March 2018 where Resident 96 had received one visit a week, so she restructured the activity staff's duties so he would get visits more frequently. The Recreation Director stated she was responsible for updating the resident's activity care plans and reviewed them monthly and updated them quarterly. When asked why Resident 96's care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 30 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 plan showed a goal for the resident to receive three room visits a week, the Recreation Director stated she had him set for three days a week because she made him a focus patient, but there was not enough activity staff for him to receive three room visits a week.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §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 observation, interview, and medical record review, the facility failed to ensure one of 30 final sampled residents (Resident 48's) was provided with assistive devices to prevent injury. Resident 48 had a physician's order for floor mats; however, the facility failed to ensure the floor mats were in place. This failure put the resident at a higher risk for fall related injuries. Findings: Medical record review for Resident 48 was initiated on 4/24/18. Resident 48 was readmitted to the facility on 12/25/17. Resident 48 had a physician's order dated 7/5/18, for bilateral mats on the floor and a low bed. Review of Resident 48's care plan for falls FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 31 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 showed the resident had falls on 12/26/17, 10/8/17, 3/11/18, and 5/19/18. The care plan interventions included to place the floor mats on both sides of the resident's bed. On 7/24/18 at 1020 hours, a concurrent observation and interview was conducted with Resident 48. Resident 48's bed was observed in the low position. The Resident 48 stated they she had falls in the past and got up when she wanted to use her walker. On 7/25/18 at 1354 hours, Resident 48 was observed lying in bed with her eyes closed. The bed was in the low position, but there were no floor mats in place. On 7/31/18 at 1351 hours, Resident 48 was observed lying in bed with the bed in the low position and a walker next to the bed. There were no floor mats located on either side of the resident's bed. On 7/31/18 at 1353 hours, an interview was conducted with Resident 48's assigned CNA, CNA 1. CNA 1 stated they had been taking care of Resident 48 over the past 3-4 months and was not aware the resident had any falls. When asked if Resident 48 had fall interventions in place, CNA 1 stated the resident did not need any floor mats. Upon observing the resident in their bed, CNA 1 verified the resident's bed was in the low position and no floor mats were in place. On 7/31/18 at 1358 hours, an interview and medical record review was conducted with Resident 48's nurse, LVN 1. LVN 1 stated the resident had falls in the past but did not have an order for a low bed or floor mats. Upon observing the resident, LVN 1 stated Resident 48's bed was currently in the low position since she was sleeping and verified there were no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 32 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 floor mats in place. LVN 1 stated when Resident 48 was awake, the bed was elevated so the resident could get out of bed on her own and ambulate using the walker. LVN 1 reviewed Resident 48's physician's orders and acknowledged there was an order for floor mats. On 7/31/18 at 1546 hours, an interview was conducted with the DON. The DON stated on 7/5/18, during room rounds, she saw Resident 48 did not have floor mats in place. The DON stated they were needed and were care planned as a fall intervention so she obtained an order to reinstate the floor mats.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to follow a physician's order to administer the pain medication and inform the physician about the pain for one of 30 final sampled residents (Resident 133). This had the potential for the resident's pain not being properly managed. Findings: Medical record review for Resident 133 was initiated on 7/24/18. Resident 133 was admitted to the facility on 12/29/17. Review of the Order Summary Report dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 33 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 6/27/18, showed a physician's order dated 4/25/18, to administer hydromorphone hydrochloride (an opioid pain medication) 4 mg one tablet by mouth every 8 hours as needed for moderate to severe pain. The order failed to identify the parameters for moderate pain and severe pain using a pain scale of 0-10 (with 0 = no pain to 10 = most severe pain). Review of Resident 133's care plan showed a care plan problem dated 7/17/18, addressing the resident exhibited or was at risk for alterations in comfort related to acute pain. The interventions included to utilize the pain scale, medicate the resident as ordered for pain, monitor for effectiveness and side effects, and report to the physician as indicated. Review of the Medication Administration Record for May 2018 for hydromorphone hydrochloride showed Resident 133 received hydromorphone hydrochloride on the following dates and times: - On 5/2/18 at 0121 hours and 1830 hours, Resident 133's pain level was 3. - On 5/4, 5/5, 5/7, 5/9 at 1040 hours, 5/11, 5/12, 5/14, 5/17, 5/18, 5/20, 5/21, 5/22, 5/23 at 0025 hours and 1149 hours, 5/24, 5/25, 5/26, 5/27, and 5/30/18, the pain level was 3. - On 5/9 at 1800 hours, 5/24 at 2234 hours, and 5/29/18 at 1302 hours, the pain level was 2. Review of Medication Administration Record of June 2018 for hydromorphone hydrochloride showed Resident 133 received hydromorphone hydrochloride on the following dates and times: - On 6/2 at 1150 hours, 6/3 at 1201 hours and 2350 hours, 6/4, 6/5, 6/9, 6/17, 6/19, 6/20, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 34 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 6/22, 6/23, and 6/24/18 at 1318 hours, the pain level was 3. - On 6/1/18 at 1601 hours, the pain level was 1. - On 6/7 at 0524 hours and 1333 hours, 6/8, 6/14, 6/15 at 1330 hours, 6/18 at 1230 hours, and 6/25/18 at 0230 hours, the pain level was 2. Review of Medication Administration Record of July 2018 for Hydromorphone Hydrochloride showed Resident 133 received hydromorphone hydrochloride on the following dates and times: - On 7/1/18 at 1258 hours, the pain level was 3. - On 7/11 at 2030 hours, 7/14 at 1311 hours, 7/21 at 1353 hours, and 7/25/18 at 0400 hours, the pain level was 3. - On 7/17/18 at 0412 hours, the pain level was 2. - On 7/4 at 0335 and 7/24/18 at 0505 hours, the pain level was zero On 7/25/18 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked to describe how the pain assessment was performed for Resident 133. LVN 1 stated she assessed Resident 133's pain level from 0 to 10. The pain level from 1 to 3 was mild pain, 4 to 5 was moderate pain, and 5 to 10 (5 or more) was severe pain. On 7/25/18 at 0958 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked to describe how the pain assessment was performed. RN 2 stated she assessed for a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 35 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 pain level from 0 to 10. The pain level from 1 to 3 was mild pain, 4 to 6 was moderate pain, and 7 to 10 was severe pain. On 7/25/18 at 1019 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 was asked about the pain level assessment. LVN 3 stated the pain level of zero was no pain, 1 to 3 was mild pain, 4 to 7 was moderate pain, and 8 to 10 was severe pain. On 7/27/18 at 1612 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked about pain scale assessment. RN 1 stated the pain level of zero was no pain, 1 to 3 was mild pain, 4 to 6 was moderate pain, and 7 to 10 was severe pain. RN 1 was asked why the nurses administered hydromorphone hydrochloride when Resident 133 had mild pain in May 2018, June 2018, July 2018, and no pain in July 2018. RN 1 stated the nurses should have clarified the order with the physician. When asked if the nurses had clarified the order with the physician, RN 1 was unable to provide documentation. RN 1 verified the findings.

F698 SS=G Dialysis CFR(s): 483.25(l)

F698 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 36 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 necessary care and services for two dialysis residents of 30 final sampled residents (Residents 123 and 1) to ensure the residents attained and maintained their highest physical well-being. * The facility failed to place Resident 123 on the fluid restriction as ordered and failed to monitor the I&O. Resident 123 required hemodialysis and had a history of CHF. The dialysis center sent the orders to place Resident 123 on fluid restriction and discontinue the sodium chloride supplement. These orders were not implemented, resulting in Resident 123 being transferred to the acute care hospital on 7/11/18, and admitted with fluid overload. Following the readmission to the facility on 7/14/18, the facility continued to fail to implement the orders for fluid restriction and monitor the I&O. In addition, the facility failed to consistently assess Resident 123 post dialysis treatments. This failure had the potential to cause a delay in necessary care and services to Resident 123. * The facility failed to remove Resident 1's dialysis dressing after returning from dialysis as ordered. This failure had the potential to delay facility nursing staff in identifying any issues with the resident's dialysis access site, including signs of infection and active bleeding. Findings: 1. Medical record review for Resident 123 was initiated on 7/25/18. Resident 123 was admitted to the facility on 5/8/18, readmitted on 6/12/18, and readmitted a second time on 7/14/18. a. Review of Resident 123's MDS dated 6/25/18, showed Resident 123 required supervision and setup help for eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 37 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 the History and Physical Examination dated 5/30/18, from the acute care hospital showed Resident 123 was hospitalized on 5/29/18, for hypoxic respiratory failure (low level of oxygen reaching the tissues) secondary to CHF due to fluid overload, hyponatremia (low sodium in the blood), and hyperkalemia (high potassium in the blood). Review of Resident 123's History and Physical Examination form dated 6/13/18, showed Resident 123 did not have the capacity to understand and make decisions. Review of the diagnosis section showed Resident 123 had a history of CHF. Review of Resident 123's Order Audit Report showed an order dated 6/12/18, to administer sodium chloride tablet one table by mouth two times a day for hyponatremia. However, review of the Order Audit Report showed the sodium chloride was not discontinued until 7/6/18, more than three weeks later. Review of Resident 123's Hemodialysis Communication Record dated 6/20/18, showed an order from the dialysis center to discontinue the sodium chloride supplement and place Resident 123 on a fluid restriction of 1200 ml per day. However, there was no documented evidence the resident was placed on a fluid restriction as ordered from the dialysis center even though the resident had been admitted to the acute care hospital on 5/29/18, with a diagnosis of CHF due to fluid overload. In addition, there was no care plan developed to address the resident's need to be placed on a fluid restriction of 1200 ml per day. Review of Resident 123's Progress Note dated 7/11/18 at 1208 hours, showed Resident 123 complained of chest pain and tightness and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 38 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 had difficulty breathing. The facility called 911 and the paramedics arrived and transported Resident 123 to the acute care hospital. Review of the Consultation Note - Nephrology (medical specialty dealing with the kidneys) from the acute care hospital dated 7/11/18, showed Resident 123 was admitted for acute hypoxic respiratory failure secondary to fluid overload, hyponatremia, hyperkalemia, hypertensive (high blood pressure) crisis, and encephalopathy (disease of the brain). Further review of the document showed Resident 123 had a BNP value of 709 pg/ml. According to Lexicomp, normal BNP levels are below 150 pg/ml. A value above 150 pg/ml is indicative of heart failure. Review of Resident 123's plan of care showed a care plan problem dated 7/24/18, addressing weight gain related to hemodialysis and CHF and resident at risk for fluid overload. The care plan interventions included to determine the individual fluid needs and monitor the oral intake. However, there was no documented evidence the facility was monitoring the resident's oral intake as careplanned. On 7/26/18 at 1050 hours, an interview was conducted with LVN 1. LVN 1 was asked about Resident 123's care, specifically fluid restriction and monitoring I&O. LVN 1 stated Resident 123 was not on fluid restriction, and they were not monitoring the resident's I&O. On 7/26/18 at 1126 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked about the procedure when Resident 123 went to dialysis. LVN 1 stated the licensed nurse was responsible for filling out the top portion of the Hemodialysis Communication Record, and the form was sent in a binder with the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 39 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 to dialysis. The Dialysis Center completed the middle section including any new orders and returned the form in the binder with the resident back to the facility. LVN 1 stated the licensed nurse assigned to the resident was responsible for inputting any new orders and communicating those new orders to Resident 123's PCP. On 7/26/18 at 1432 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked if Resident 123 was on a fluid restriction. The RD verified between 6/19/18, to the present, there were no orders or other documentation in the medical record regarding the resident's fluid restriction. On 7/26/18 at 1442 hours, LVN 1 was asked about the order from the dialysis center dated 6/20/18, regarding discontinuing the sodium chloride supplement. LVN 1 was unable to find any documentation Resident 123's PCP was notified of the order to discontinue the sodium chloride supplement and place the resident on a fluid restriction, or any documentation the orders were carried out. LVN 1 stated it must have been missed. On 7/30/18 at 1506 hours, a telephone interview and concurrent medical record review was conducted with the dialysis center's Dialysis RN. The Dialysis RN was asked about Resident 123's Hemodialysis Communication Record dated 6/20/18. The Dialysis RN stated the dialysis physician wrote an order for Resident 123 to be taken off the sodium chloride supplement because it made Resident 123 thirsty and Resident 123 had gained too much weight in fluid. The Dialysis RN stated Resident 123 needed the fluid restriction because Resident 123 no longer produced urine and got fluid overload. The Dialysis RN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 40 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 stated the Hemodialysis Communication Record section filled out by the dialysis center's staff was the order from their physician and she expected the facility to follow it when Resident 123 returned to the facility. On 7/30/18 at 1524 hours, an interview was conducted with CNA 9. CNA 9 was asked how she assisted Resident 123 with meals. CNA 9 stated Resident 123 ate and drank without assistance. CNA 9 stated Resident 123 requested lots of fluids and asked for more fluids in addition to what came on her meal trays. CNA 9 stated Resident 123 often requested a big pitcher full of ice upon return from dialysis. CNA 9 stated Resident 123's I&O was not being monitored. On 8/1/18 at 0953 hours, a telephone interview was conducted with Resident 123's PCP. The PCP stated he never ordered a fluid restriction for Resident 123 as the dialysis physician would order it if the resident needed it. The PCP further stated it would be the facility's responsibility to follow that order; it would have nothing to do with him. He was never notified of an order to discontinue the sodium chloride supplement or to put the resident on a fluid restriction. On 8/2/18 at 1545 hours, an observation was made of Resident 123. Resident 123 was in bed and had a one liter pitcher filled with 950 ml of water on her bedside table within reach. On 8/2/18 at 1555 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the water pitcher being at Resident 123's bedside. The DON stated Resident 123 should not have the water pitcher and she would inform Resident 123's nurse, the CNA, and dietary department. The DON was asked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 41 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 about the I&O monitoring for dialysis residents. The DON stated the facility would only monitor the I&O if the resident was on a fluid restriction and verified Resident 123 should have been on a fluid restriction. When asked what was expected of the licensed nurse when they received the resident from the dialysis center with a new order, the DON stated the licensed nurse should call the resident's PCP, tell them the recommendation, and input the order. On 8/2/18 at 1620 hours, a follow-up interview was conducted with the RD. The RD was asked when she assessed Resident 123. The RD stated the first time Resident 123 was assessed was 6/19/18. The RD stated she recommended to discontinue Resident 123's zinc sulfate and add a renal multivitamin with minerals and a supplement for wound healing. There were no recommendations regarding the resident's fluid needs. When asked how she determined the interventions for Resident 123, the RD stated she looked at Resident 123's diagnoses, history and physical, and hospital notes. The RD stated she did not recall seeing anything about the fluid overload or CHF in Resident 123's medical record. The RD stated she assessed Resident 123 again on 7/20/18. When asked why Resident 123 was not placed on a fluid restriction or monitoring after her return from the acute care hospital, the RD stated she was not informed Resident 123's latest admission to the acute care hospital was due to a fluid overload. The RD stated she must have missed why Resident 123 was hospitalized. On 8/2/18 at 1640 hours, an interview and concurrent medical record review was conducted with LVN 8 and the DON. LVN 8 stated he was assigned to care for Resident 123 during the 3-11 shift on 6/20/18. LVN 8 stated he received Resident 123 from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 42 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 dialysis treatment on 6/20/18, and wrote a Progress Note but did not sign the Hemodialysis Communication Record. LVN 8 stated it was his responsibility to review the Hemodialysis Communication Record for any new orders, but he did not recall why he did not input the order from dialysis or notify Resident 123's PCP. When asked who was supposed to sign the Hemodialysis Communication Record, the DON stated the receiving nurse. On 8/2/18 at 1648 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked who signed the Hemodialysis Communication Record dated 6/20/18. The DON stated the form was signed by RN 6. The DON stated RN 6 was no longer employed by the facility. b. Review of the Hemodialysis Communication Records showed the following: - Resident 123 received dialysis treatment on 7/6/18; however, the post-dialysis assessment was not completed by the licensed nurse until 7/8/18. - Resident 123 received dialysis treatment on 7/16/18; however, the sections to be completed by the dialysis center and the post-dialysis assessment were left blank. - Resident 123 received dialysis treatment on 7/18/18; however, the post-dialysis assessment was left blank. - Resident 123 received dialysis treatment on 7/20/18; however, the post-dialysis assessment was dated 7/23/18. 2. Medical record review for Resident 1 was initiated on 7/24/18. Resident 1 was readmitted to the facility on 7/21/18, with end stage renal failure and was receiving dialysis. Review of Resident 1's physician's orders showed the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 43 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 * An order dated 7/21/18, for dialysis every Monday, Wednesday, and Friday. * An order dated 7/18/18, to monitor the resident's hemodialysis site every shift for signs or symptoms the site. Notify the physician at the dialysis center immediately with any urgent problems. * An order dated 7/21/18, to remove the dressing from the dialysis shunt (a connection surgically created to connect a vein and an artery to access for the dialysis treatments) after four hours, scheduled every Monday, Wednesday, and Friday. On 7/26/18 at 1526 hours, Resident 1 was observed sleeping in bed. A gauze dressing was noted on the resident's right bicep area. On 7/26/18 at 1552 hours, an interview was conducted with LVN 2. LVN 2 verified Resident 1's dialysis site dressing was still present from the previous day. LVN 2 stated the dressing should have been removed last night, usually six hours after returning from the dialysis center. When LVN 2 was asked how he assessed Resident 1's dialysis site, LVN 2 stated he checked for the bruit (the sound of blood passing through the shunt) and thrill (the feel of the blood passing through the shunt) through the dressing and did not visually assess the site. LVN 2 then removed the dialysis dressing and assessed the site. On 7/26/18 at 1624 hours, a concurrent interview and medical record review was conducted with Medical Records Staff 1. When asked to locate Resident 1's dialysis site dressing removal order on the Treatment Administration Record, Medical Records Staff 1 stated the order dated 7/21/18, was entered as an ancillary order and would not show in the resident's electronic treatment record as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 44 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 needing to be completed by the nurse. On 7/31/18 at 0918 hours, Resident 1 was observed in bed. A gauze dressing was noted on the resident's right bicep area. On 7/31/18 at 0919 hours, and interview was conducted with RN 1. RN 1 verified the gauze dressing from the previous day's dialysis treatment was still in place and should have been removed after dialysis. RN 1 verified Resident 1 last received dialysis yesterday. RN 1 removed the dressing and assessed the site.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 45 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to ensure the nursing staff administered the medications as per the standards of practice for two of 30 final sampled residents (Residents 10 and 133). The facility failed to administer the medications as ordered and document on the MAR when the medications were administered to Residents 10 and 133. This posed the risk for medical complications and medication administration errors for the residents. Findings: 1. Review of the facility's P&P titled Medication Administration - General dated 7/24/18, showed to document the administration of medication on the MAR. Review of the facility's P&P titled Medication Error dated 7/17/14, showed evaluate the patient for adverse effects. Report immediately to the DON or designees. Notify physician/midlevel provider, patient, and responsible party. Obtain orders, if indicated. Initiate orders if any. Monitor the patient. The person discovering the incident will enter it into the Risk Management System (RMS) as a new event. Investigate the incident and implement interventions to prevent further errors. Medical record review for Resident 133 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 46 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 initiated on 7/24/18. Resident 133 was admitted to the facility on 12/29/17. Review of the Order Summary Report dated 6/27/18, showed a physician's order dated 2/13/18, to administer ferrous sulfate (iron supplement) 325 mg (65 Fe), one tablet by mouth three times a day for supplement, on 12/29/17 to administer gabapentin (anticonvulsant) 400 mg, one capsule by mouth every eight hours for neuropathy, and Humalog (insulin) solution 100 unit/ml (Insulin Lispro) inject as per the following sliding scale: if 0-12 = 0 (no insulin), 121-160 = 3 (units of insulin), 161-190 = 4, 191-210 = 5, 211-240 = 6, 241270 = 7, 271-300 = 8, 301-330 = 9, 331-360 = 10, 2361-400 = 12, subcutaneous every morning and at bedtime for sliding scale insulin coverage for diabetes; call the physician for anything greater than 400 and anything less than 70. Another order dated 4/9/18, showed to administer insulin glargine solution 100 unit/ml, inject 16 units subcutaneous at bedtime for type 2 diabetes. Another order dated 4/17/18, showed to administer MS Contin (morphine sulfate) tablet Extended Release 15 mg, one tablet by mouth every 12 hours for moderate to severe pain. An order dated 12/29/17, showed to administer sennosides 8.6 mg, one tablet by mouth at bedtime for constipation. An order dated 7/5/18, showed to administer tizanidine hydrochloride 2 mg, one tablet by mouth three times a day for muscle relaxant. Review of the MAR for July 2018 showed the following: - On 7/12/18, ferrous sulfate, MS Contin, Insulin glargine, tizanidine was scheduled to be administered at 2100 hours. - On 7/12/18, gabapentin and sennosides was scheduled to be administered at 2200 hours, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 47 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 - On 7/12/18, Humalog solution administration per the blood sugar sliding scale was scheduled to be administered at 2000 hours, -On 7/12/18, check and record blood pressure and pulse every shift for hypertension (high blood pressure) and monitor signs or symptoms of infection in urine for indwelling catheter use every shift and monitor pain using pain scale 0-10 and non-pharmacological interventions used before as needed pain medication or antianxiety, antidepressant or sedative/hypnotic use was blank, - On 7/12/18, monitor depression by verbalizing feelings of sad, depression, flat effect, loss of hope, monitor episodes for muscle spasms by tally and harshmark, monitor episodes of muscle spasms every shift tally by harshmark for the 3 to 11 hours shift was blank. There was no documentation on the MAR to show the medications were administered. On 7/30/18 at 1530 hours, a concurrent interview and concurrent medical record review was conducted with RN 1 and the DON. RN 1 and the DON were asked if Resident 133 had filed a grievance two weeks ago regarding medication administration. RN 1 and the DON stated she spoke with the nurse (LVN 6) and LVN 6 was given an inservice. RN 1 stated the DON checked the Medication Administration Record, the medications were given later around 1200 or 0200 hours. The blood sugar was not that night. LVN 6 told her they had short staffing. Cross reference to F585. On 7/30/18 at 1600 hours, a concurrent interview and concurrent medical record review was conducted with the DON. The DON was asked to show if the nurse informed the physician and assessed the resident after the medications and the blood sugar checked was late. The DON stated she was unable to locate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 48 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 documentation. The DON was asked to show any documentation of the investigation with LVN 6 and other staff. The DON stated she was unable to show the documentation. The DON and RN 1 only interviewed LVN 6 and the resident. The DON stated she did not have a chance to speak with LVN 6 because LVN 6 was no longer working. The DON was asked if this incident affected others. The DON stated everyone got their medications on time when she checked the Medication Administration Records. On 7/30/18 at 1610 hours, an interview was conducted with RN 1. RN 1 was asked if Resident 133 was informed of the resolution of her grievance filed on 7/13/18. RN 1 did not answer. On 7/31/18 at 0949 hours, an interview and concurrent medical record review was conducted with the DON. When the DON was asked if the blood sugar was checked and the insulin was administered at 0200 hours, the DON stated yes. The DON was asked if she could show any documentation the routine medications for the 3 to 11 shift were given around 1200 to 0200 hours and the blood sugar check and insulin were given around 0200 hours. The DON was unable to show any documentation. The DON stated LVN 3 was not savvy with the computer program; they sent her to a computer class. The DON stated Resident 133 told her LVN 6 told her she had 40 residents. On 7/31/18 at 1400 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked to show documentation LVN 6 was given an inservice about medication administration and the computer. The DON stated she was unable to show any documentation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 49 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 2. Medical record review was initiated for Resident 10 on 2/27/18. Resident 10 was admitted to the facility on 2/1/16. Review of the Order Summary Report dated 6/27/18, showed a physician's order dated 2/2/16, to administer docusate sodium 100 mg one tablet by mouth every 12 hours for constipation twice a day. Do not crush or chew. Hold for loose stools. Review of Resident 10's MAR for July 2018 showed the following: - On 7/12/18, on the 3-11 shift, for nonpharmacological interventions, monitor episodes of anxiety manifested by restlessness, insomnia, over concern every shift, monitor for side effects: drowsiness, sedation, weakness, dry mouth and increased confusion, monitor for depakote, encourage oral fluids, monitor for verbalization of hallucination seeing spiders on walls and ceiling, monitor pain using pain scale 0-10 was blank. - On 7/12/18, on the 3-11 shift, the area to document the administration of docusate sodium scheduled to be administered at 2100 hours was blank. On 8/1/18 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked if she could show any documentation on the Medication Administration Record for 7/12/18, on the 3 to 11 shift, if monitoring was done and medication for 2100 was given. The DON acknowledged she was unable to show any documentation. The DON verified the findings.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5) FORM CMS-2567(02-99) Previous Versions Obsolete

F756 Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 50 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 51 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 by: Based on interview, and medical record review, the facility failed to ensure one of five unnecessary medication sampled residents (Resident 50) was free from unnecessary medication. The facility failed to act upon the Pharmacy Consultant's repeated recommendations for Resident 50's drug regimen review and the facility failed to ensure Resident 50 had documentation a drug regimen review was completed monthly. This resulted in a delay of notifying Resident 50's physician of the Pharmacy Consultant's recommendations and posed a risk of providing Resident 50 with unnecessary medication and the potential for development of significant side effects. Findings: Medical record review for Resident 50 was initiated on 7/30/18. Resident 50 was readmitted to the facility on 2/17/18. Review of Resident 50's physician's orders showed the following: * An order dated 7/27/17, for lorazepam (antianxiety medication) 0.5 mg by mouth every eight hours PRN for anxiety/agitation. There was no time limit identified for the use of the lorazepam PRN. * An order dated 4/17/18, for lorazepam 0.5 mg by mouth every eight hours PRN for anxiety. There was no time limit identified for the use of lorazepam. Review of Resident 50's Consultation Report completed by the Pharmacy Consultant dated 3/13/18, showed following: Repeated recommendation from 2/26/18: Please respond promptly to assure facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 52 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 compliance with Federal Regulations Repeated recommendation from 1/29/18: Please respond promptly to assure facility compliance with Federal Regulations Repeated recommendation from 12/12/17: Please respond promptly to assure facility compliance with Federal Regulations Repeated recommendation from 11/20/17: Please respond promptly to assure facility compliance with Federal Regulations. (Resident 50) has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: lorazepam 0.5 mg PRN. The Pharmacy Consultant's recommendations showed to discontinue the PRN lorazepam order. The Pharmacist's recommendations also showed if the medication could not be discontinued at this time, current regulations require the prescriber document the indication for use, the intended duration of therapy, and the rational for the extended time period. A handwritten note at the bottom of the form dated, "4/" by a facility staff member showed the physician was notified and discontinued the lorazepam order. Review of a physician's order dated 4/17/18, showed to administer Lorazepam 0.5 mg one tablet by mouth as needed for anxiety. Review of Resident 50's Consultation Report dated 4/24/18, showed Resident 50 had a PRN order for an anxiolytic without a stop date: lorazepam PRN order dated 4/17/18. The Pharmacy Consultant recommended to discontinue the PRN lorazepam order after 14 days (on 5/1/18). The Pharmacy Consultant's recommendations also showed if the mediation could not be discontinued at this time, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 53 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 current regulations required the prescriber document the indication for use, intended duration of therapy, rational for the extended time period, and duration for the PRN order. On 7/31/18 at 0827 hours, an interview was conducted with the DON. The DON stated she found the Pharmacy Consultant's recommendations for April 2018, for Resident 50 at the nurses' station that morning, not in the drug regimen review binder where it should have been located. The DON verified the Pharmacy Consultant's recommendation was not acted upon by facility staff. In a follow-up interview on 7/31/18 at 0901 hours, the DON stated she discontinued the PRN lorazepam order on 4/15/18, (146 days after the Pharmacy Consultant's initial recommendation.) The DON stated she was not aware the medication had been reordered on 4/17/18, (two days later) resulting in a new Pharmacist's recommendation on 4/26/18. The DON was asked to provide documentation of drug regimen reviews for Resident 50 for May, June and July 2018. In a follow-up interview conducted with the DON on 7/31/18 at 1010 hours, the DON stated she was unable to locate any prescriber documentation showing the Pharmacy Consultant's recommendations had been acted upon by either discontinuing Resident 50's lorazepam order or prescriber documentation showing the rational for and duration of the medication's extended use. On 7/31/18 at 1544 hours, the DON stated the facility was unable to locate any evidence drug regimen reviews were completed for Resident 50 for the months of May, June, and July 2018. Cross reference to F758. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 54 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F758 Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 55 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of five unnecessary medication sampled residents (Resident 50) was free from an unnecessary medication. The facility failed to ensure Resident 50 was reevaluated by the physician for the appropriateness of the continued use of PRN (as needed) lorazepam (antianxiety medication). This posed a risk of providing Resident 50 with unnecessary medication and the potential for development of significant side effects. Findings: Medical record review for Resident 50 was initiated on 7/30/18. Resident 50 was readmitted to the facility on 2/17/18. Review of Resident 50's physician's orders showed the following: * An order dated 7/27/17, for lorazepam 0.5 mg by mouth every 8 hours PRN for anxiety/agitation. There was no time limit identified for the use of lorazepam. * An order dated 4/17/18, for lorazepam 0.5 mg by mouth every 8 hours PRN for anxiety. There was no time limit identified for the use of lorazepam. The Pharmacy Consultant addressed the concern of Resident 50's order for the use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 56 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 lorazepam PRN every eight hours. In an interview conducted with the DON on 7/31/18 at 1010 hours, the DON stated she was unable to locate any prescriber documentation for Resident 50's lorazepam use to discontinue after 14 days or for the rational and duration of the extended use. Cross reference to F756.

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

F761 §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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 57 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 Based on observation, interview, and facility P&P review, the facility failed to ensure the routine and controlled medications were locked and the keys to all medications were always in the possession of a licensed nurse. This had the potential for diversion of controlled medications and access of controlled medications by unlicensed staff. Findings: Review of the facility's P&P titled Management of Controlled Substances dated 7/1/13, showed: - The management of controlled drugs including storage and destruction is conducted under the direction and ultimate responsibility of the Executive Director and Resident Care Director. - Narcotic keys for the locked boxes/cabinets must always be in the possession of the licensed nursing staff. On 7/26/18 at 1452 hours, an interview and concurrent observation concerning the controlled medications was conducted with the DON. The DON was asked where she kept the controlled medications awaiting destruction. The DON stated she kept the controlled medications awaiting destruction in a pad locked cabinet at her desk. When the DON was asked to open the cabinet, she retrieved a set of keys from a glass jar sitting on her desk and unlocked the pad lock of the cabinet. The drawer contained many bubble packs of various controlled medications. The DON stated when she was not in the office, her door was closed and locked. On 7/26/18 at 1522 hours, the door to the DON's office was observed to be open and no one was in the office. This finding was verified by RN 5 and CNA 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 58 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 On 7/27/18 at 1545 hours, the door to the DON's office was observed to be open and no one was in the office. This finding was verified by LVN 5. On 8/1/18 at 1545 hours, a medication cart was observed in the hallway near Room A to be unlocked and unattended. RN 3 verified this finding. RN 3 summoned LVN 4 who was observed walking from the nurses' station to the where the medication cart was located. LVN 4 stated this medication cart was hers and had just been endorsed to her by the off going nurse.

F803 SS=D Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 59 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure the dietary staff served one final sampled resident (Resident 90) with food according to their preference. This posed the risk of the resident's nutritional needs not being met. Findings: On 7/25/18 at 0830 hours, Resident 90 was observed not eating the two yolks of two hard boiled eggs. Resident 90 stated she spoke with staff and the night nurse to have scrambled eggs for every breakfast instead of hard boiling eggs. Resident 90 pressed the call light. A Central Supply staff member came in and asked Resident 90 if she needed help. Resident 90 informed the staff member she wanted scrambled eggs for breakfast every day. The Central Supply staff member turn off the call light. On 7/26/18 at 0836 hours, Resident 90 was observed served hard boiling eggs for breakfast and stated they still gave her hard boiled eggs instead scrambled eggs. CNA 6 verified the resident had two hard boiled eggs and no scrambled eggs on her tray. On 7/26/18 at 0850 hours, an interview was conducted with the central supply staff member who responded to Resident 90 the previous morning. When asked what the central supply staff member did after Resident 90 told him about her food preference yesterday, the central supply staff member stated he reported to the Dietary Manager Resident 90 wanted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 60 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 scrambled eggs every morning, immediately. On 7/26/18 at 0900 hours, the Dietary Manager was asked if he got any message from the central supply staff member about a resident's food preference. The Dietary manager stated the central supply staff member told him Resident 90 wanted scrambled eggs but did not mention if it was for breakfast, dinner or lunch. On 7/31/18 at 1037 hours, an interview and medical record review was conducted with the Dietary Manager. The Dietary Manager was asked about a revised care plan to update Resident 90's preference for scrambled eggs at breakfast. The Dietary Manager acknowledged the care plan was not revised and still showed the resident had hard boiled eggs for breakfast. The Dietary Manager verified the finding.

F842 SS=B Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 61 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 62 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were completed for one of 30 final sampled residents (Resident 59). This had the potential for the resident's care needs not being met as the clinical information was not complete. Findings: Review of the facility's P&P titled Clinical Record: Charting and Documentation revised 1/1/13, showed the purpose is to provide a complete account of the total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. Chart as often as necessary and as the need arises. Under the requirements for different categories of provider coverage, the P&P showed under Medicaid: By exception or as required by state agency. Medical record review for Resident 59 was initiated on 7/27/18. Resident 59 was admitted to the facility on 2/14/18. Review of Resident 59's medical record showed facility staff documented regularly until 6/20/18, and no further entries until 7/10/18, when the CNA reported Resident 59 refused care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 63 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 On 7/27/18 at 0909 hours, an interview and concurrent medical record review concerning Resident 59 was conducted with RN 3 who identified herself as a Unit Manager. RN 3 was unable to explain why there was no documentation since 6/20/18, and stated the documentation should show at least a weekly assessment and a weekly skin assessment. RN 3 verified the medical record did not contain a weekly nurse's assessment or a weekly skin assessment from 6/20/18 to 7/27/18.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 64 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 65 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 Based on observation, interview, facility P&P review, and facility document review, the facility failed to establish and maintain infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections for two of 30 final sampled residents (Residents 65 and 108) and two of four nonsampled residents (Residents 16 and 67). * The facility failed to ensure LVN 2 practiced sanitary techniques during the medication administration. This posed the risk for transmission of disease-causing microorganisms. Findings: 1. According to the CDC's guidelines, hand hygiene is performed: - Before and after having direct contact with a resident's intact skin (taking pulse or blood pressure, performing physical examinations). - After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. - After glove removal. According to the facility's P&P titled Hand Washing revised 6/15/18, hand washing is performed: - After touching bare parts of the body other than clean hands and exposed portion of arms. - After contacting any soiled equipment or utensils. - When moving from one task to another. On 7/26/18 at 0904 hours, a medication administration pass was conducted with LVN 2. LVN 2 washed his hands and donned gloves. LVN 2 checked Resident 16's respiratory rate by placing the stethoscope over Resident 16's heart. LVN 2 did not wash his hands after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 66 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 touching the stethoscope and prior to preparing Resident 16's medications for administration. LVN 2 was observed emptying capsules filled with medication into a medicine cup with his bare hands. LVN 2 administered the medications to Resident 16. LVN 2 then moved on to Resident 67. LVN 2 did not perform hand hygiene after moving from Resident 16 to Resident 67. LVN 2 was observed opening the medication cart, wiping his nose with the back of his hand, and then removing medications for Resident 67. LVN 2 then administered the medications to Resident 67. On 7/26/18 at 1008 hours, an interview was conducted with LVN 2. LVN 2 was asked when he would wash his hands during medication administration. LVN 2 stated he would normally wash his hands after being in contact with a resident, or before leaving their room. LVN 2 further stated he would wash his hands when moving from one resident to another. LVN 2 verified he did not wash his hands after using the stethoscope on Resident 16, nor did he wash his hands before he began preparing medications for Resident 67. LVN 2 stated he did not wash his hands prior to leaving the residents' room. 2. On 7/24/18 at 0750 hours, Resident 65 was observed in bed with a portable nebulizer on the right side of the floor mattress. The face mask and tubing were observed on the floor, connected to breathing treatment. On 7/24/18 at 0930 hours, CNA 5 was in the room standing in front of the bathroom to assist the resident in the bathroom. The breathing machine was observed on the right floor mattress. The face mask and tubing were observed on the floor. On 7/24/18 at 1010 hours, RN 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 67 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 summoned to Resident 65's room. RN 1 verified Resident 65's portable nebulizer, face mask and tubing were observed directly touching the floor. 3. On 7/24/18 at 0800 hours, Resident 108 had a nasal cannula tubing on the floor. On 7/24/18 at 1016 hours, RN 1 was summoned to Resident 108's room. RN 1 verified Resident 108 had a nasal cannula touching the floor.

F917 SS=D Resident Room Bed/Furniture/Closet CFR(s): 483.10(i)(4), 483.90(e)(2)(3)

F917 §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv) §483.90(e)(2) -The facility must provide each resident with-(i) A separate bed of proper size and height for the safety and convenience of the resident; (ii) A clean, comfortable mattress; (iii) Bedding, appropriate to the weather and climate; and (iv) Functional furniture appropriate to the resident's needs, and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident. §483.90(e)(3) CMS, or in the case of a nursing facility the survey agency, may permit variations in requirements specified in paragraphs (e)(1) (i) and (ii) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations (i) Are in accordance with the special needs of the residents; and (ii) Will not adversely affect residents' health and safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 68 of 69 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: _______________ 555765 (X3) DATE SURVEY COMPLETED 08/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (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 This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure one of 30 final sampled resident's (Resident 17) bedside nightstand was maintained and functional. This failure resulted in Resident 17 being upset their personal belongings and monies were not secured. Findings: On 7/26/18 at 0810 hours, a concurrent observation and interview were conducted with Resident 17 in their room. Resident 17 had a nightstand with drawers located next to their bed. The nightstand's top drawer front was observed hanging off, held in place by the padlock affixed to the side of the cabinet and drawer front. Resident 17 stated the drawer front had fallen off three months ago and no one had come in to fix it. The resident stated she was upset because she locked her personal belongings in that drawer and did not want people going through her belongings. Resident 17 stated the maintenance staff knew about it but had not fixed it. On 7/26/18 0832 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the night stand's upper drawer front had fallen off. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4F9W11 Facility ID: CA060000094 If continuation sheet 69 of 69