Other·September 10, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the concurrent RECERTIFICATION and ABBREVIATED surveys to investigate COMPLAINT No. CA00646511. Representing the California Department of Public Health: Surveyor 37689, HFEN; Surveyor 38461, HFEN; Surveyor 38489, HFEN; Surveyor 40432, HFEN; Surveyor 41231, HFEN; Surveyor 41324, HFEN; and Surveyor 41418, HFEN. FOR COMPLAINT NO. CA00646511: THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FINDINGS WERE CITED AT F688 FOR RESIDENT 82. The surveyors entered the facility on 7/29/19 at 0730 hours. The census was 143. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living AV fistula - surgically created connection between an artery and a vein Bruit - the sound heard through a stethoscope over the AV fistula Central line - an intravenous catheter inserted into a large vein in the neck or chest CNA - Certified Nursing Assistant Dermatologist - a medical practitioner qualified to diagnose and treat skin disorders DON - Director of Nursing DSD - Director of Staff Development DSS - Dietary Services Supervisor EOP - Emergency Operations Plan GT - gastrostomy tube (a tube inserted through the wall of the abdomen directly into 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: EQNZ11 Facility ID: CA060000094 If continuation sheet 1 of 77 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 08/05/2019 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 stomach used to administer nutritional formula and/or medications gm - gram(s) Hemodialysis/dialysis - a treatment to rid the blood of toxins and waste when the kidneys fail to function IDT - Interdisciplinary Team IV - intravenous (a special "needle" inserted into a vein connected to plastic tubing to administer fluids and/or medication) LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) mmHg - millimeters of mercury (a unit of blood pressure measurement mg - milligram(s) mg/dl - milligram per deciliter ml - milliliter(s) iu - international unit(s) P&P - policy and procedure PROM -passive range of motion RD - Registered Dietitian RN - Registered Nurse RNA - Restorative Nursing Assistant ROM - range of motion RNA - Restorative Nursing Assistant SSA - Social Services Assistant Thrill - a vibration felt over the AV fistula Trendelenberg - positioning a person on their back and elevating the feet higher than the head.

F550 SS=B 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 2 of 77 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 08/05/2019 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(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. §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: 2. During the observations on 7/31/19 between 0751 and 0829 hours, the following was observed: - At 0757 hours, CNAs 4 and 5 entered Room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 3 of 77 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 08/05/2019 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 G carrying breakfast trays without knocking on the door and waiting for the residents' response. - At 0803 hours, CNA 6 entered Room B without knocking to ask Resident 35 what she was calling out for. - At 0806 hours, CNA 7 entered Room H carrying a breakfast tray without knocking on the door. Two residents were still in bed. - At 0810 and 0812 hours, CNA 6 entered Rooms I and J respectively, without knocking on the door. The residents were still in the room. - At 0814 hours, CNA 8 entered Room K without knocking on the door. There were residents in the room. - At 0829 hours, CNA 9 entered Room L carrying a breakfast tray without knocking on the door. On 7/31/19 at 0814 hours, CNA 8 was asked what the facility's policy was regarding providing privacy when entering a resident's room. CNA 8 stated the staff should knock on the door prior to entering a resident's room. CNA 8 verified she did not knock on the door prior to entering Room K. On 7/31/19 at 0829 hours, CNA 9 was asked what the facility's policy was when entering a resident's room. CNA 9 stated the staff should knock on the door when the door was closed. CNA 9 was asked about if the resident's door was open and the resident was in the room. CNA 9 was unable to respond and stated she thought she would only knock when the door was closed. On 7/31/19 at 0838 hours, the DSD was asked what the facility's policy was with regards to providing privacy during care and entering the resident's room or bathroom. The DSD stated the staff should knock on the resident's door or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 4 of 77 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 08/05/2019 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 bathroom prior to entering, introduce themselves, call the residents by name, and close the curtain when providing care. The DSD was informed and acknowledged the above findings.Based on observation and interview, the facility failed to ensure one of 28 final sampled residents (Resident 43) was provided care in a manner that promoted dignity and respect. The facility failed to ensure staff members knocked before entering multiple residents' rooms. * A facility staff without an ID badge was observed entering multiple residents' rooms without knocking. * The facility failed to ensure the resident's private space was protected and valued by knocking on the door prior to entering the resident's room. * The facility failed to ensure Resident 43's urinary drainage bag was covered by a privacy bag (conceals fluid in the drainage bag to promote dignity). These had the potential to negatively affect the residents' well-being. Findings: 1. On 7/31/19 at 0815 to 0837 hours, a male staff member without an ID badge was observed pushing a cart filled with boxes of towel dispensers. The male staff member parked his cart by Room A and entered the room without knocking. Two female residents were inside the room. The male staff member was observed going in and out of the rooms without knocking, took out the existing paper towel dispensers, and installed new ones from his cart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 5 of 77 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 08/05/2019 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 male staff member was observed doing the same thing to Rooms B and C with the residents inside the rooms. On 7/31/19 at 1020 hours, the same male staff member without an ID badge was observed with a cart filled with paper towel rolls. The male staff member was observed entering Room E without knocking. A family member was inside the room. The family member verified the male staff member did not knock before entering the room. The male staff member was observed entering Rooms D and F without knocking. The residents were inside the rooms. When the male staff member asked who he was, the male staff member identified himself as the Maintenance Assistant and stated he had left his ID badge in his office. On 7/31/19 at 1045 hours, the Maintenance Assistant was informed of the above observations and acknowledged the findings. 3. On 7/29/19 at 0802 hours, an observation of Resident 43 was conducted. Resident 43's urinary drainage bag was observed without a privacy bag, hanging on the left side of the bed. The urinary drainage bag was observed to have 500 ml of clear, amber drainage which was visible from the hallway. On 7/29/19 at 1701 hours, an observation of Resident 43 and a concurrent interview was conducted with LVN 2. Resident 43's urinary drainage bag was observed without a privacy bag, hanging on the left side of the bed. The urinary drainage bag was observed to have 300 ml of clear, amber drainage and was visible from the hallway. LVN 2 verified the findings and stated it should have been covered with a privacy bag to provide dignity to Resident 43. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 6 of 77 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 08/05/2019 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

F583 Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/05/2019 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 7 of 77 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 08/05/2019 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 medical record review, the facility failed to ensure the privacy was maintained during care for one of 28 final sampled residents (Resident 78). The facility failed to ensure Resident 78 was provided full visual privacy during care and treatment. This posed the risk of exposing the resident's body to other residents, staff, and visitors and had the potential to negatively affect the resident's dignity. Findings: Review of Resident 78's medical record was initiated on 7/29/18. Resident 78 was readmitted to the facility on 5/23/19. Review of the MDS dated 6/5/19, showed Resident 78 had severe cognitive impairment. Resident 78 needed extensive assistance from one staff member during toileting, dressing and personal hygiene. Resident 78 was incontinent of bowel and bladder. On 7/31/19 at 1601 hours, Resident 78's abdomen and thighs were observed exposed upon entering his room. CNA 12 was observed changing Resident 78's incontinence brief. Resident 78's privacy curtain was not drawn during the care. Resident 78's door was left wide open. Facility staff were observed walking by in the hallway. On 7/31/19 at 1610 hours, a concurrent observation and interview was conducted with the DSD and CNA 12. CNA 12 acknowledged she left the privacy curtain open and did not close the door. The DSD stated Resident 78's privacy curtain had to be drawn to provide privacy and dignity.

F641 Accuracy of Assessments FORM CMS-2567(02-99) Previous Versions Obsolete

F641 Event ID: EQNZ11 08/27/2019 Facility ID: CA060000094 If continuation sheet 8 of 77 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 08/05/2019 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=A CFR(s): 483.20(g) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: The facility was in substantial compliance with the requirement of 42 CFR, Part 483, Subpart B. 42 CFR 483.20(g) Medical record review for Resident 116 was initiated on 8/1/19. Resident 116 was admitted to the facility on 12/27/17. Review of the quarterly MDS dated 6/26/19, showed section E0900 (wandering - presence and frequency) was coded three (showing wandering occurred daily). Further review of the MDS showed Resident 116 required extensive assistance of one person for locomotion on and off the unit. Review of the plan of care failed to show a care plan problem was developed to address Resident 116's wandering behavior. On 8/1/19 at 0954 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated she was not aware of Resident 116's wandering behavior. On 8/1/19 at 1011 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA stated she was responsible for coding Section E of the MDS and coded Resident 116 for wandering because she saw the family member pushing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 9 of 77 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 08/05/2019 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 Resident 116 around the facility every day. The SSA acknowledged she coded Resident 116's wandering behavior inaccurately.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 09/05/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 10 of 77 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 08/05/2019 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 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 a comprehensive plan of care for one of 28 final sampled residents (Resident 78). * Resident 78 was assessed to have a communication problem; however, a care plan problem was not developed to show interventions to address the communication problem. This failure placed Resident 78 at risk of not having his care needs met. Findings: Review of Resident 78's medical record was initiated on 7/29/18. Resident 78 was readmitted to the facility on 5/23/19. Review of the MDS dated 6/5/19, showed Resident 78 had severe cognitive impairment. Resident 78 spoke a foreign language and needed an interpreter to communicate with a physician or the health care staff. Review of Resident 78's care plan showed there was no care plan problem developed to address Resident 78's communication needs. On 7/29/19 at 0900 hours, during the initial tour, Resident 20 stated he had concerns about Resident 78 because he could not be understood by the staff. Resident 20 stated the staff was not able to communicate with Resident 78. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 11 of 77 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 08/05/2019 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 07/29/19 1028 hours, an interview was conducted with Resident 78's Family Member 1. Family Member 1 stated she had concerns about how the facility communicated with Resident 78. Family Member 1 the facility had to call her to interpret for Resident 78. Family Member 1 stated Resident 78 and another family member spoke a foreign language and hardly spoke any English. On 7/31/19 1630 hours, an interview was conducted with RN 3. RN 3 stated Resident 78 spoke a foreign language. When asked what interventions were in place to address Resident 78's communication needs, RN 3 stated there were none. RN 3 stated a care plan problem should have been developed to include approaches to address Resident 78's communication needs. Cross reference to

F676, example #2.

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 10/10/2019 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 12 of 77 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 08/05/2019 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 must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the communication devices were provided to two of 28 final sampled residents (Residents 78 and 108) who did not speak English. This failure had the potential of Residents 78 and 108 not being able to communicate their care needs to the staff. Findings: 1. On 7/29/19 at 1019 hours, a concurrent observation and interview were conducted with RN 4 during initial tour of the facility. RN 4 was observed at the bedside of Resident 108 communicating in English. Resident 108 did not respond verbally to RN 4. RN 4 stated Resident 108 did not understand English, so she communicated with the resident using hand gestures. When asked how the staff communicated with the residents who did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 13 of 77 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 08/05/2019 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 speak English, RN 4 stated the facility did not have translation phones, computers, books, or interpreters to assist with communication. Medical record review for Resident 108 was initiated on 7/30/19. Review of the MDS dated 6/19/19, under Section A, it showed Resident 108 needed an interpreter to communicate with the physician or staff. Review of Resident 108's care plan showed a care plan problem dated 6/3/19, to address a communication problem. The Interventions/Tasks included to provide the preferred language interpreter services as needed and involve family to interpret when available, use of gestures and observe changes in facial expressions and body language, and monitor the effectiveness of communication strategies and assistive devices. On 7/30/19 at 1131 hours, an interview was conducted with CNA 11. CNA 11 was asked how she communicated with residents who did not speak English. CNA 11 stated when she encountered a resident who did not speak English, she communicated using hand gestures and by pointing to body parts (her own) and waited for the resident to respond. CNA 11 stated she asked the residents if the resident wanted this and waited for the resident to nod their head. CNA 11 stated the facility did not have translators, interpretation phones, or communication boards. RN 3 interrupted the interview and informed CNA 11 there were communication boards at the bedside of every resident who did not speak English. CNA 11 entered two rooms housing residents who did not speak English and verified there were no communication boards at the bedsides. CNA 11 entered Resident 108's room and reported a communication board was at the bedside. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 14 of 77 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 08/05/2019 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 CNA 11 stated she had never seen communication boards during her employment at the facility. CNA 11 stated she had no idea how to properly use the guide since she had not seen it before and had not been trained in its use. 2. On 7/29/19 at 0900 hours, Resident 20 stated he had concerns about Resident 78 who kept calling out but was not understood by staff. Resident 20 stated the facility staff was not able to communicated with Resident 78. Review of Resident 78's medical record was initiated on 7/29/18. Resident 78 was readmitted to the facility on 5/23/19. Review of the MDS dated 6/5/19, showed Resident 78 had severe cognitive impairment. The MDS showed Resident 78 spoke a foreign language and needed an interpreter to communicate with the physician or staff. Resident 78 needed extensive assistance from one staff member during toileting, dressing, and personal hygiene. Resident 78 was incontinent of bowel and bladder. On 7/29/19 at 1000 hours, Resident 78's voice was heard calling to staff in a foreign language. Resident 78 was coughing. On 7/31/19 at 0945 hours, Resident 78's family member was in Resident 78's room. Resident 78's family member did not speak English. On 7/29/19 1028 hours, an interview was conducted with Family Member 1. Family Member 1 stated she had concerns about how the facility communicated with Resident 78. Family Member 1 stated the facility had to call her to interpret for Resident 78. Family Member 1 stated Resident 78 and another family member spoke a foreign language and did not speak English. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 15 of 77 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 08/05/2019 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 7/31/19 at 0945 hours, a concurrent observation and interview was conducted with CNA 13. CNA 13 stated Resident 78 was totally dependent on one to two staff members for his ADL care. CNA 13 stated Resident 78 only spoke and understood a foreign language. CNA 13 stated Resident 78's family member who was usually at his bedside only spoke a foreign language. When asked how she communicated with Resident 78, she stated she used gestures. When asked how she knew what Resident 78 wanted, CNA 13 stated it was usually for incontinence care. CNA 13 stated a communication board may be present at Resident 78's bedside. CNA 13 walked into Resident 78's room and searched for a communication board. CNA 13 verified there was no communication board. When asked if she had used a communication board to communicate with Resident 78, CNA 13 stated no. On 7/31/19 at 1011 hours, a concurrent observation and interview was conducted with CNA 14. CNA 14 stated Resident 78 was unable to press the call light. CNA 14 stated he had to check on Resident 78 to see what he needed. CNA 14 stated he communicated with Resident 78 using gestures. When asked how he knew what Resident 78 needed, CNA 14 stated it was always incontinence care. CNA 14 verified there was no communication board in Resident 78's room. On 7/31/19 at 1615 hours, a concurrent observation and interview was conducted with CNA 12. CNA 12 stated Resident 78 spoke a foreign language. Resident 78 spoke to CNA 12 in a foreign language. CNA 12 approached Resident 78 and told him to speak English. When asked if Resident 78 was able to speak English, CNA 12 stated he knew some words. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 16 of 77 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 08/05/2019 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 When asked what words Resident 78 had spoken in English, CNA 12 was unable to say. Resident 78 continued speaking to CNA 12 in a foreign language. CNA 12 left Resident 78's room. On 7/31/19 1630 hours, an interview was conducted with RN 3. RN 3 stated Resident 78 spoke a foreign language and was not able to use his call light. When asked her how the staff knew what care needs he had, RN 3 stated the staff had to check on him frequently. When asked what interventions were in place to address Resident 78's communication needs, RN 3 stated they had to call Family Member 1 to interpret for him. RN 3 stated a communication board had to be at bedside for the staff to use. Cross reference to F656.

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

F679 10/10/2019 §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 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 provide an ongoing activity program to meet the needs and interests of one of 28 final sampled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 17 of 77 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 08/05/2019 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 residents (Resident 76). The facility failed to provide Resident 76 with an individualized activity program which met her identified preference of listening to music. This had the potential to negatively impact the resident's well-being. Findings: On 7/29/19 at 1025 hours, Resident 76 was observed lying in bed with her eyes closed. The television was observed to be off and pushed by the wall away from Resident 76. There was no radio nor any in-room sensory stimulation observed. Medical record review for Resident 76 was initiated on 7/29/19. Resident 76 was admitted to the facility On 4/26/18. On 7/30/19 at 0943 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 76 did not get out of bed. CNA 3 stated he did not provide any activity for Resident 76 in the resident's room. On 7/30/19 at 0918 and 1116 hours, and on 7/31/19 at 0808 and 1449 hours, Resident 76 was observed lying in bed with her eyes closed. The television was observed to be off and pushed by the wall away from Resident 76. There was no radio nor any in-room sensory stimulation observed. Review of the Activity - Quarterly Evaluation dated 6/5/19, showed Resident 76 enjoyed listening to music. Review of the plan of care showed a care plan problem dated 6/5/19, to address Resident 76's little or no activity involvement related to physical limitations. The interventions included for Resident 76 to be provided with music per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 18 of 77 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 08/05/2019 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 her family's request. Review of the One-to-One Activity Participation Documentation for July 2019 showed Resident 76 was only provided music on 7/10 and 7/17/19. On 8/1/19 at 0843 hours, an interview was conducted with the Activities Director. The Activities Director stated when she did the activities evaluation, Resident 76 did not respond, so the family member was interviewed regarding the resident's preferences. The Activities Director stated Resident 76's family member did not want her to listen to music; however, after reviewing her activity evaluation, the Activities Director verified Resident 76 preferred to listen to music. A concurrent observation was conducted with the Activities Director in Resident 76's room. Resident 76 was observed lying in bed with her eyes closed. The television was on and the volume was low. The Activities Director verified there was no radio in the room for Resident 76 to listen to music.

F684 SS=D Quality of Care CFR(s): 483.25

F684 10/10/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 19 of 77 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 08/05/2019 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 record review, the facility failed to provide the necessary care and services to ensure two of 28 final sampled residents (Residents 5 and 58) and one nonsampled resident (Resident 7) attained and maintained their highest practicable physical well-being. * The facility failed to ensure the injection sites for insulin injections were rotated for Resident 5. This failure created the risk of causing tissue injury due to repeated injections in the same site and interfere with absorption of the insulin. * The facility failed to follow the physician's order to monitor Resident 7's blood pressure every six hours. This had the potential for Resident 7's high blood pressure go undetected and untreated. * The facility failed to follow a physician's order to reschedule a dermatology appointment for Resident 58. This failure caused the resident unnecessary discomfort and potentially exposed the resident to unnecessary infections. Findings: 1. According to the FDA Highlights of Prescribing Information for insulin aspart revised 2/2015, under Adverse Reactions, showed to rotate injection sites to reduce the risk of lipodystrophy (the loss of local fat deposits as a complication of repeated insulin injections into the same subcutaneous tissue). Review of Resident 5's medical record was initiated on 7/29/19. Resident 5 was readmitted to the facility on 1/9/18. Review of the Order Summary Report dated 6/27/19, showed an order dated 5/31/19, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 20 of 77 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 08/05/2019 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 administer insulin aspart based on the sliding scale (the dose of insulin is determined by the blood sugar level obtained just prior to administering the insulin), subcutaneously (between the skin and muscle) three times a day. Review of Resident 5's Location of Administration Reports for June and July 2019 showed the injection sites used to administer the insulin injections were not consistently rotated. For example, Resident 5 received insulin aspart in the following injection sites: - On 6/21/19 at 1630 hours, insulin was injected in the rear portion of the right upper arm. - On 6/22/19 at 2000 hours, insulin was injected in the rear portion of the right upper arm. - On 6/26/19 at 1630 hours, insulin was injected in the rear portion of the right upper arm. - On 6/27/19 at 1630 and 2000 hours, insulin was injected in the rear portion of the right upper arm. - On 6/28/19 at 1630 and 2000 hours, insulin was injected in the rear portion of the right upper arm. - On 6/29/19 at 1630 and 2000 hours, insulin was injected in the rear portion of the right upper arm. - On 7/2/19 at 1630 and 2000 hours, insulin was injected in the rear portion of the right upper arm. - On 7/15/19 at 1630 hours, insulin was injected in the rear portion of the right upper arm. - On 7/16/19 at 2100 hours, insulin was injected in the rear portion of the right upper arm. - On 7/17/19 at 1630 hours, insulin was injected in the rear portion of the right upper arm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 21 of 77 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 08/05/2019 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 7/30/19 at 1140 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 verified Resident 5's insulin injections were not rotated. RN 3 stated insulin sites had to be rotated to prevent the development of lipodystrophy where Resident 5's insulin medication may not be absorbed properly. 2. Medical record review for Resident 7 was initiated on 8/1/19. Resident 7 was admitted to the facility on 2/17/17. Review of the Order Summary Report showed a physician's order dated 5/1/19, to monitor Resident 7's blood pressure every six hours. Review of the Medication Administration Record for July 2019 showed an order to monitor Resident 7's blood pressure every six hours. However, the blood pressure was scheduled to be monitored every shift at 0700 to 1500, 1500 to 2300, and 2300 to 0700 shifts. On 7/27 on the 2300 to 0700 hours shift, 7/28/19 on the 0700 to 1500 hours and 1500 to 2300 hours shifts, the blood pressure reading was exactly the same at 150/79 mmHg. Review of the Weights and Vitals Summary showed the blood pressure reading of 150/79 mmHg was obtained on 7/28/19 at 0037 hours. There was no blood pressure readings obtained for the 0700 to 1500 hours and 1500 to 2300 hours shifts on 7/28/19. Further review of the Weights and Vitals Summary for July 2019 showed Resident 7's blood pressure readings had been unstable ranging from 118/70 to 173/92 mmHg. On 8/1/19 at 1547 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 reviewed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 22 of 77 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 08/05/2019 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 and verified the above findings. RN 3 stated the reason for the above similar blood pressure readings shown in the Medication Administration Record was because the licensed nurses used the previous blood pressure reading instead of obtaining a new one. 3. On 7/29/19 at 1624 hours, an observation and concurrent interview was conducted with Resident 58. Multiple open, red sores were observed on Resident 58's face, neck, chest, and arms. Resident 58 stated the sores were itching. Resident 58 stated she went to a dermatology appointment about three weeks ago but was not seen by the dermatologist. Resident 58 could not recall the exact date. Resident 58 stated she was unaware of the reason why she was not seen by the physician, and stated the appointment had not been rescheduled. Resident 58 stated LVN 4 was aware the appointment needed to be rescheduled. Medical record review for Resident 58 was initiated on 8/2/19. Resident 58 was readmitted to the facility on 6/8/18. Review of the history and physical examination dated 7/3/19, showed Resident 58 was capable and independent in making decisions. Review of the physician's orders showed an order dated 7/2/19, for Resident 58 to follow up with the dermatologist on 7/3/19 at 1000 hours. A subsequent physician's order dated 7/9/19, showed an order for a dermatology appointment for Resident 58; however, no documented evidence was provided showing the appointment was ever rescheduled. On 8/2/19 at 0945 hours, LVN 4 stated Resident 58 was not seen by the dermatologist on 7/3/19, because she did not have a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 23 of 77 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 08/05/2019 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 companion with her at the appointment. An interview was conducted with RN 3 on 8/2/19 at 1518 hours. RN 3 stated, according to the dermatology office, upon arriving to the scheduled appointment on 7/3/19, Resident 58 was not seen by the dermatologist because the office was small and crowded, requiring the resident to wait outside. The office staff did not allow Resident 58 to stay outside alone without a family or staff member present. The RN verified the appointment had not been rescheduled.

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

F688 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of 28 final sampled residents (Resident 82) was provided necessary treatment and services to maintain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 24 of 77 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 08/05/2019 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 and improve his ROM functions. The facility failed to provide RNA services for PROM exercises to Resident 82 as ordered by the physician. The facility failed to notify the physician and address the reason for Resident 82's documented refusals of the RNA services. This posed the risk for Resident 82 to develop complications from immobility leading to muscle atrophy and contractures (shortening of the tendons and muscles causing the joints to become stiff and unable to fully function). Findings: On 7/29/19 at 1101 hours, an interview was conducted with Resident 82. Resident 82 brought up a concern regarding not receiving his range of motion exercises as ordered by the physician. Resident 82 stated he did not receive any RNA services last week, and he knew how important it was for him to receive the range of motion exercises through the RNA because he could not move his body from the neck down. Medical record review for Resident 82 was initiated on 7/29/19. Resident 82 was readmitted to the facility on 2/26/18. Review of the MDS dated 6/7/19, showed Resident 82 had no impairment in cognition. Review of the Order Summary Report showed a physician's order dated 11/13/18, for RNA services to provide PROM to the bilateral upper and lower extremities three times per week. The order did not include the duration of the treatment. Review of the Restorative Nursing Record for July 2019 showed Resident 82 was to receive RNA services for PROM to the bilateral upper and lower extremities three times per week. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 25 of 77 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 08/05/2019 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 record showed multiple blank entries indicating RNA services were not provided three times a week per the physician's order. For example, from 7/23 to 7/26/19, no RNA services were provided to Resident 82. Review of the Progress Notes showed a Restorative Nursing entry dated 5/31/19, for an IDT meeting attended by the DON, the Director of Rehabilitation and the RNAs. The IDT note showed Resident 82 tolerated the PROM program well and had no changes in his ROM or functional performance. However, review of the Restorative Nursing Record for May 2019 showed Resident 82 only received RNA services on 5/3 and 5/4/19, and had refused the RNA services for the rest of the month of May 2019. Review of the medical record showed no documentation the physician was informed of Resident 82's refusals, nor any documentation the DON or the Director of Rehabilitation had addressed Resident 82's refusals. Further review of the Progress Notes showed a Restorative Nursing entry dated 6/28/19 at 1418 hours, for an IDT meeting attended by the DON, the Director of Rehabilitation and the RNAs. The note showed "...RNA reports that despite ROM efforts with resident; resident does not feel ROM." The IDT recommended to continue the RNA program, to document refusals, and to re-offer as tolerated. Review of the medical record failed to show documentation the DON or the Director of Rehabilitation had discussed the concern with Resident 82. On 7/29/19 at 1641 hours, a follow up interview was conducted with Resident 82. When Resident 82 was asked about the documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 26 of 77 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 08/05/2019 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 refusals for the RNA services, he shook his head and stated he did not refuse most of the time. Resident 82 stated it was either a new staff member was assigned to do it, or the staff did not come back at a later time. Resident 82 stated he was tired teaching the new staff how to do the ROM appropriately. When asked if anyone from Nursing or the Rehabilitation Department had discussed the concern with him, Resident 82 replied no. On 7/30/19 at 1152 hours, an interview and concurrent medical record review was conducted with RNA 2. RNA 2 reviewed the Restorative Nursing Record for July 2019 and verified the RNA services were not provided three times a week as ordered by the physician. RNA 2 stated if the entry was blank, it meant, no RNA services were offered because they should document any refusal and inform the charge nurse right away. RNA 2 verified the RNA order did not include the duration of the treatment, and stated she did it for 15 to 30 minutes. On 7/30/19 at 1412 hours, an interview and concurrent medical record review was conducted with the Director of Rehabilitation. The Director of Rehabilitation reviewed the IDT meeting entry dated 5/31/19, and verified the entry was inconsistent with the documentation of the actual RNA services provided to Resident 82. The Director of Rehabilitation stated the note was based on what the RNAs had reported during the meeting. When asked if they reviewed the Restorative Nursing Record during their IDT meeting, the Director of Rehabilitation stated he would ask the RNAs to bring their RNA binders to the meeting moving forward. The Director of Rehabilitation stated the RNAs reported Resident 82 was refusing the RNA services because he was "...not feeling the ROM." When asked if he had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 27 of 77 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 08/05/2019 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 how the RNAs provide the PROM exercises or discussed this concern with Resident 82, the Director of Rehabilitation stated no.

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, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 14) was free from accident hazards. * The facility failed to ensure their P&P was implemented when Resident 14 was identified missing in the facility. The EOP to announce "code pink" was not activated as soon as Resident 14 was identified missing. This failure resulted in the other facility staff not being aware Resident 14 was missing. Only two staff searched for Resident 14 for one and a half hours, resulting in a delay in the notification of appropriate authorities. Findings: According to the facility's undated P&P titled Missing Resident, the initial actions to take when a resident was identified missing was to activate the facility's EOP by announcing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 28 of 77 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 08/05/2019 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 "Code Pink" and appoint a Facility Incident Commander if warranted. Search the facility's grounds for the resident. Keep a record of the areas searched. If the missing resident is not found following an expedient search, call 911. Notify the Orange County District Office Department of Public Health for unusual occurrence and activation of the facility's EOP. On 7/29/19 at 0750 hours, an entrance conference was conducted with the Operations Manager. The Operations Manager stated he was the acting Administrator. The Operations Manager did not mention any unusual occurrence, nor the activation of the facility's EOP. On 7/29/19 at 0800 hours, during the initial tour of the facility, Resident 14 was observed not being in his room. An interview was conducted with LVN 7. When asked where Resident 14 was, LVN 7 stated he might be having coffee. Resident 14's roommate overheard the conversation and stated Resident 14 was missing. LVN 7 stated the roommate was not reliable, but she will find out where Resident 14 was. LVN 7 stated she did not get any report from the outgoing nurse regarding Resident 14. On 7/29/19 at 0902 hours, an interview was conducted with the Operations Manager. The Operations Manager verified Resident 14 was missing since last night (7/28/19) and he was trying to get hold of the licensed nurse who worked when Resident 14 went missing. The Operations Manager stated he did not have information about Resident 14 right now. The Operations Manager stated he only learned about Resident 14 being missing this morning when he came to work. The Operations Manager stated the licensed nurse called his cell phone at 2345 hours last night, but his cell phone did not ring. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 29 of 77 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 08/05/2019 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 7/29/19 at 1103 hours, an interview was conducted with LVN 7. LVN 7 stated he worked the 1500 to 2300 hours shift last night and was assigned to Resident 14. LVN 7 stated he last saw Resident 14 around 2030 hours, and at around 2100 hours, CNA 15 reported Resident 14 was missing. LVN 7 stated they did not activate the EOP to announce "Code Pink," so both he (LVN 7) and CNA 15 went to search for Resident 14 inside and outside the facility. At around 2230 hours, LVN 7 stated he called the Police Department and reported Resident 14 missing. LVN 7 stated he informed the oncoming nurse about Resident 14 missing but did not inform the oncoming nurse he was not able to get hold of the Operations Manager nor DON. LVN 7 also stated he did not generate an incident report nor document the areas he searched. On 7/29/19 at 1612 hours, an interview was conducted with CNA 15. CNA 15 stated she provided care to Resident 14 on 7/28/19, during the 1500 to 2300 hours shift. CNA 15 stated she reported to LVN 7 Resident 14 was missing at around 2100 hours. CNA 15 stated the facility's emergency code for elopement was "code pink;" however, she did not hear LVN 7 announce "code pink," so only her and LVN 7 searched for Resident 14. Closed medical record review for Resident 14 was initiated on 7/29/19. Resident 14 was admitted to the facility on 4/20/18. Review of the quarterly MDS dated 7/17/19, showed Resident 14 had no cognitive impairment. On 8/1/19 at 1639 hours, the Operations Manager was informed and acknowledged the above findings. Resident 14 was still missing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 30 of 77 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 08/05/2019 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 as of this time.

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services for GT feedings for one of 28 final sampled residents (Resident 78). * Resident 78 was placed in a Trendelenberg position during ADL care, which resulted in coughing episodes. This failure placed Resident 78 at risk for aspiration. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 31 of 77 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 08/05/2019 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 78's medical record was initiated on 7/29/18. Resident 78 was readmitted to the facility on 5/23/19. Review of the MDS dated 6/5/19, showed Resident 78 had severe cognitive impairment. Resident 78 had a GT. Review of Resident 78's Order Summary Report dated 6/27/19, showed an order dated 5/24/19, to elevate the head of the bed 30-45 degrees during and one hour after feeding. An order dated 5/1/19, showed Resident 78 was to receive Jevity 1.2 cal via pump at 40 ml per hour for 20 hours or until total nutrient was delivered. Downtime from 10 AM to 2 PM. Review of Resident 78's care plan showed a care plan problem addressing gastroesophagela reflux (when stomach contents go back up the esophagus). The interventions included to avoid lying down for at least one hour after meals and keep the head of the bed elevated. Monitor for coughing, choking, when lying down. A care plan problem addressing Resident 78's tube feeding related to dysphagia (difficulty swallowing), showed interventions to keep the head of the bed elevated at all times during feeding. On 7/29/19 at 0859 hours, Resident 78's head of the bed was elevated. Resident 78's feeding pump was running at 40 ml per hour. Resident 78 had gurgling sounds while sleeping. On 7/31/19 at 1601 hours, CNA 12 was observed providing incontinence care to Resident 78. Resident 78 was observed lying in a Trendelenberg position. Resident 78's GT feeding was put on hold. On 7/31/19 at 1610 hours, a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 32 of 77 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 08/05/2019 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 observation and interview was conducted with the DSD. The DSD stated Resident 78's GT feeding had been started and was put on hold. The DSD stated Resident 78's head of the bed could be placed in a flat position during ADL care. The DSD acknowledged Resident 78 was in a Trendelenberg position. When asked why the head of the bed should not be in a low position, the DSD stated Resident 78 was at risk for aspiration pneumonia. On 7/31/19 at 1612 hours, Resident 78 while in a Trendelenberg position started coughing. CNA 12 elevated Resident 78's head of the bed. CNA 12 acknowledged she positioned Resident 78's head of the bed too low for a long time. CNA 12 stated she had to lower down Resident 78's head of the bed to provide ADL care. When asked why Resident 78's lower body was positioned higher than his head, CNA 12 stated she had to change the resident's incontinence brief.

F694 SS=D Parenteral/IV Fluids CFR(s): 483.25(h)

F694 § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. 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 IV medications were administered according to facility policy and procedure and professional standards of practice for two nonsampled residents (Residents 13 and 547). This posed the risk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 33 of 77 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 08/05/2019 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 residents to develop complications such as catheter-related infections, air embolism (blood vessel blocked by air), and low Vancomycin (antibiotic medication) levels or toxicity. * The facility failed to ensure handwashing was provided as per the facility's P&P and professional standards of practice before IV medications were administered to Residents 13 and 547. * The facility failed to ensure the injection ports of the intravenous lines were cleaned according to professional standards of practice before the IV was used to administer medications to Residents 13 and 547. * The facility failed to ensure air was properly expelled from a prefilled normal saline syringe according to professional standards of practice prior to pushing fluid through Resident 547's central line. * The facility failed to ensure a Vancomycin trough (the level of Vancomycin in the blood) was obtained as ordered for Resident 547. * The facility failed to ensure RN 1 attended mandatory IV training classes. Findings: Review of the facility's P&P titled Handwashing dated 5/2007 showed handwashing was considered the most important single procedure for preventing infections. The P&P showed effective handwashing included rubbing the hands in a circular motion for not less than 15 seconds, to rub between the fingers for 15 seconds and to rinse the hands with warm water. 1a. On 7/31/19 at 1049 hours, RN 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 34 of 77 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 08/05/2019 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 preparing and administering Vancomycin to Resident 547 through a central line. During the preparation and administration of the medications for Resident 547, RN 1 performed handwashing four times. For each occurrence, RN 1 was observed turning on the water, dispensing soap from the dispenser onto her hands, and running her hands under the water for a total of three seconds. RN 1 then dried her hands with a paper towel and continued the medication administration process for Resident 547. b. On 7/31/19 at 1257 hours, RN 1 was observed preparing and administering Vancomycin to Resident 13 through an IV. During the preparation and administration of the medication to Resident 13, RN 1 performed handwashing three times. For each occurrence, RN 1 was observed turning on the water, dispensing soap from the dispenser onto her hands, and running her hands under the water for a of total three seconds. RN 1 then dried her hands with a paper towel and continued the medication administration process for Resident 13. During an interview with RN 1 on 7/31/19 at 1320 hours, RN 1 stated the purpose of handwashing was to prevent infection. RN 1 stated the facility's policy showed hands should be washed for 30-60 seconds and acknowledged the above handwashing occurrences for Residents 547 and 13 were not in compliance with the facility's policy. 2a. Review of the facility's P&P titled IV medication Administration (undated) showed, during medication administration, the nurse should vigorously scrub the injection port of the resident's IV line with an alcohol wipe for at least 15 seconds and hold the injection port and let the alcohol air dry for 15 seconds. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 35 of 77 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 08/05/2019 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 Joint Commission publication titled Preventing Central Line-Associated Bloodstream Infections Useful Tools: Scrub the Hub! dated 11/20/13, showed the hub (an injection port) of an IV catheter was a potential portal of entry for infection. The professional standard of practice for adequate scrubbing of the hub prior to IV medication administration was essential. The scrub the hub process included rubbing the hub for 10 to 15 seconds using an alcohol prep pad generating friction by scrubbing in a twisting motion as if one were juicing an orange, and allow the hub to dry. The tool also showed the prep pad (the alcohol wipe) should never be reused. On 7/31/19 at 1049 hours, RN 1 was observed administering IV medication into Resident 547's central line. RN 1 wiped the injection port of the central line with an alcohol prep pad for one second and placed the used alcohol prep pad on the bed. RN 1 attached a 10 ml syringe of normal saline onto the injection port, flushed the IV tubing with the saline and checked for blood return. RN 1 removed the syringe from the injection port, picked up the used alcohol prep pad from the bed and wiped the IV injection port again for one second. The bag and tubing for the IV Vancomycin was attached to the central line injection port and infused into Resident 547. On 7/31/19 at 1100 hours, RN 1 stated the purpose of cleaning the IV injection port was to remove the bacteria because the injection port rested on Resident 547's skin and in the bed. RN 1 stated the injection port of an IV tube should be scrubbed for 30-60 seconds. RN 1 stated cleaning the injection port would help prevent infection to the resident and acknowledged the IV injection port was not cleaned according to professional standards of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 36 of 77 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 08/05/2019 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 practice. b. Review of the Joint Commission Resource titled Clinical Care Improvement Strategies: Preventing Air Embolism (undated) showed infusing medications through central line IV catheters was a medical procedure that puts an individual at greatest risk for air embolism (blood vessel blockage caused by one or more bubbles of air). Air embolism can occur during even the most simple of practices, such as when a clinician administers an intravenous push medication and lets any air that remains in the syringe go into the patient. According to the manufacturer's directions, before attaching the syringe to the resident, the cap of the pre-filled normal saline flush syringe should is to be removed, and holding the syringe upright (with the tip of the syringe up), the air and any excess fluid is to be expelled by pushing on the syringe plunger. On 7/31/19 at 1049 hours, RN 1 was observed preparing and attaching a 10 ml prefilled normal saline syringe for Resident 547. Prior to attaching the syringe to Resident 547's IV port, RN 1 did not expel the air from the syringe. On 8/1/19 at 0808 hours, the DON was informed of the above findings. c. Medical record review was initiated for Resident 547 on 7/31/19. Review of Resident 547's physician's orders dated 7/26/19, showed to administer 1 gram of Vancomycin intravenously one time a day. A second order showed to obtain a blood sample for a VT (Vancomycin Trough). The VT was ordered to be obtained on 7/29/19, the fourth day after starting the Vancomycin. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 37 of 77 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 08/05/2019 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 Medication Administration Record and laboratory results showed Resident 547 received daily doses of Vancomycin from 7/26 - 8/2/19, and did not have the VT laboratory test done as ordered on 7/29/19. On 8/2/19 at 1323 hours, an interview was conducted with the Laboratory Supervisor. The Laboratory Supervisor verified a request was not received from the facility for the laboratory technician to come and draw blood from Resident 547 on 7/29/19 or 7/30/19. The Laboratory Supervisor verified the VT blood sample was not obtained for Resident 547 until 8/2/19, five days after it was ordered to be obtained. The laboratory requisitions dated 7/29/19, and 7/31/19, showed Resident 547 refused to have the laboratory samples drawn; however, the Laboratory Supervisor verified a laboratory technician was not at the facility those dates to draw a VT. No documentation could be found in Resident 547's medical record or on the laboratory log showing the resident refused to have the VT drawn on the above dates. Review of the laboratory results from 8/1/19, showed the Vancomycin trough level was very high at 28/6 ug/ml (microgram per milliliter). The normal range for the trough level was 5 10 ug/ml. During an interview on 8/2/19 at 1435 hours with RN 3, RN 3 acknowledged the laboratory test for Resident 547 was drawn five days after it was ordered to be obtained. 3. Review of the facility's P&P titled IV medication Administration (undated) showed the nurse should have an understanding of his or her scope of practice according to facility policy and/or state laws and be responsible to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 38 of 77 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 08/05/2019 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 maintain a level of competence needed for the safe delivery of any infusion therapy. Review of RN 1's Medication Administration Competency Worksheet dated 6/6/19, show competency was not verified for IV medication administration. Review of the facility's Inservice Information Records for medication administration were reviewed. The following in-services were provided by the facility: - 6/13/19, Survey Tips and IV Medication Pass; - 7/25/19, Central Line Care and Maintenance. In-service was provided by the pharmacy and included a skills evaluation; - 7/25/19, Survey Tips and IV Medication Pass. Review of the name and titles of the facility staff who attended the in-services showed RN 1 did not attend any of the above in-services. On 8/2/19 at 0856 hours, an interview was conducted with the DON. The above inservices were reviewed with the DON. The DON stated the IV medication in-services were mandatory for the RNs giving IV medications. The DON verified RN 1 did not attend the above in-service training for IV medication administration.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 10/10/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 39 of 77 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 08/05/2019 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, interview, and medical record review, the facility failed to provide safe respiratory care for two of 28 final sampled residents (Residents 25 and 43). * The facility failed to ensure the physician was notified of a change in Resident 43's oxygen saturation (level of oxygen in the blood). This posed the risk for delayed care and interventions. In addition, the facility failed to ensure Resident 43's oxygen saturation was monitored as ordered by the physician. This had the potential of Resident 43 receiving unnecessary oxygen. * The facility failed to ensure orders to administer oxygen to Resident 25 had indications and parameters. This posed a risk of Resident 25 receiving unnecessary oxygen. Findings: 1. Medical record review for Resident 43 was initiated on 7/31/19. Resident 43 was readmitted to the facility on 11/15/18. Review of Resident 43's Order Summary Report date 7/31/19, showed an order dated 7/24/19, to administer oxygen continuously at 3 liters per minute via nasal cannula (a tube with two prongs inserted into the nostrils to administer the oxygen). Another order dated 7/25/19, showed to monitor the resident's oxygen saturation level (the amount of oxygen in the blood) every shift, remove oxygen for five minutes, then check oxygen saturation on room air. There was no parameter identified for the use of oxygen, i.e. the oxygen saturation rate to be maintained. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 40 of 77 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 08/05/2019 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 Progress Notes showed an entry dated 7/26/19, showing Resident 43 was transferred to an acute care hospital for low oxygen saturation ranging from 75-85% despite receiving 15 liters of oxygen per minute via mask (a device which covers both the mouth and nose, used to deliver oxygen). Resident 43 was transferred back to the facility on 7/28/19. Review of the Weights and Vitals Summary dated 7/29/19 at 0722 hours, showed Resident 43's oxygen saturation was at 84%, "low of 94.0 exceeded." However, review of the Progress Notes and assessment records did not show documentation of any assessment, intervention, or notification to the physician. On 7/31/19 at 1445 hours, an interview was conducted with LVN 1. When asked about contacting the physician, LVN 1 stated she would have to call the physician if the oxygen saturation was below 92%. LVN 1 was asked about the lack of documentation for Resident 43's low oxygen saturation on 7/29/19. LVN 1 verified there was no documentation of any intervention, assessment or notification to the physician. On 8/2/19 at 1338 hours, a telephone interview was conducted with RN 2. RN 2 was assigned to care for Resident 43 on 7/29/19. RN 2 verified she did not call the physician regarding the change in the resident's condition and did not document any interventions done regarding the low oxygen saturation. 2. Medical record review for Resident 25 was initiated on 7/30/19. Resident 25 was readmitted to the facility on 2/3/13. Review of Order Summary Report dated 6/27/19, showed a physician's order dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 41 of 77 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 08/05/2019 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 5/28/19, to administer oxygen at 2 - 4 liters per minute via nasal cannula as needed; however, the order did not have any parameters or an indication for use. On 7/30/19 at 0908 hours, an observation of Resident 25 was conducted. Resident 25 was observed receiving oxygen at 3.5 liters per minute via nasal cannula. On 7/30/19 at 0941 hours, an interview was conducted with RN 1. When RN 1 was asked how she or other nurses knew when to give Resident 25 oxygen. RN 1 stated there should be a parameter identified in the order. RN 1 checked Resident 25's oxygen saturation on room air and it was 95%. RN 1 stated she needed to call the physician to clarify the order.

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

F698 10/10/2019 §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, medical record review, and facility P&P review, the facility failed to ensure necessary care and services were provided for two of 28 final sampled residents (Residents 5 and 132) regarding dialysis care. * The facility failed to ensure Resident 5's dialysis access site was assessed. The facility failed ensure Resident 5's blood pressure was not taken from her right arm. In addition, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 42 of 77 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 08/05/2019 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 facility failed to assess Resident 5's medical condition when she came back from dialysis. These posed the risk for development of medical problems related to the resident's need for dialysis. * The facility failed to ensure Resident 132 was administered the medications as ordered by the physician on the days the resident left the facility for dialysis. This had the potential for Resident 132 not receiving the appropriate doses of medications as ordered, resulting in health complications. Findings: According to facility's P&P titled Renal Dialysis, Care of Resident, Hemodialysis Access Site, Plan of Care, the AV fistula and AV graft sites are checked for condition, bruit and thrill every shift. Blood pressures will not be performed on the extremity where the fistula is located. Record assessment of hemodialysis access site in the medication administration record, nurses' notes and nursing/dialysis communication record. The facility licensed nurse will complete the baseline information, pre and post dialysis section of the Dialysis Communication Record. 1a. Review of Resident 5's medical record was initiated on 7/29/19. Resident 5 was readmitted to the facility on 1/9/18, with a diagnosis of end stage renal disease requiring hemodialysis. Review of the MDS dated 7/12/19, showed Resident 5 was cognitively intact. Resident 5 was on dialysis. Review of the Order Summary Report dated 6/27/19, showed an order dated 1/15/18, for Resident 5 to go to dialysis on Mondays, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 43 of 77 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 08/05/2019 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 Wednesdays and Fridays. There was no order to assess Resident 5's AV fistula. Review of the Medication Administration Records dated June and July 2019 did not show Resident 5's AV fistula was assessed. Review of the Dialysis Communication Records from June 2019 to July 2019 did not show Resident 5's AV fistula was consistently assessed. Review of the acute care hospital's Patient Discharge Instruction dated 6/11/19, showed Resident 5 had an AV Fistula Placement. Under the section titled Care After AV Fistula, showed to feel for thrill and bruit on the access site. On 7/29/19 at 0944 hours, during initial tour, Resident 5 was observed sitting in her wheelchair by the side of her bed. Resident 5 stated she had dialysis three times in a week. Resident 5 was observed to have a gauze dressing on her right forearm. When asked about the dressing, Resident 5 stated she just had an AV fistula placed on her right arm. Resident 5 stated the AV fistula was not ready for dialysis use. Resident 5 stated she used the catheter on her right upper chest during dialysis. When asked if staff checked the AV fistula, Resident 5 stated the staff did not do anything with it. On 7/30/19 at 0940 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 stated Resident 5 had an AV fistula on her right forearm. RN 3 stated she was not aware if the AV fistula was assessed by staff. When asked if the AV fistula had to be assessed, RN 3 stated the AV fistula had not matured yet and was not used for dialysis. RN 3 verified Resident 5's AV fistula FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 44 of 77 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 08/05/2019 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 not assessed in the pre dialysis and post dialysis assessments. RN 3 verified there was no documented evidence to show Resident 5's AV fistula was assessed regularly. On 8/2/19 at 1000 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 5 had a catheter on the chest and did not have an AV fistula. On 8/2/19 at 1035 hours, an interview was conducted with the Dialysis RN. The Dialysis RN stated thrills and bruits had to be assessed on residents with AV fistula. The Dialysis RN stated even though the AV fistula had not matured yet, assessments had to be performed to ensure the AV fistula was functioning. b. Review of Resident 5's Order Summary Report dated 6/27/19, showed an order dated 1/19/18, not to take blood pressures on Resident 5's right arm. Review of the acute care hospital's Patient Discharge Instruction dated 6/11/19, showed Resident 5 had an AV Fistula Placement and not to allow blood pressures to be taken on the arm where the AV fistula was located. On 7/29/19 at 0944 hours, during initial tour, Resident 5 was observed sitting in her wheelchair by the side of her bed. Resident 5 was observed with a gauze dressing on her right forearm. Resident 5 stated the facility staff took her blood pressure on her right arm. On 7/30/19 at 0940 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 stated Resident 5 had an AV fistula on her right forearm. RN 3 stated Resident 5's blood pressure had to be taken on the left arm to preserve the function of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 45 of 77 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 08/05/2019 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 AV fistula on the right arm. On 7/30/19 at 1111 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 5 had a dry dressing covering a wound on her right forearm. CNA 1 stated the "wound" must be for dialysis. When asked which arm was used to take Resident 5's blood pressure, CNA 1 stated she took the blood pressure on Resident 5's right wrist. CNA 1 stated it should be okay to take it from the right wrist since it was below the "wound." On 8/2/19 at 1009 hours, an interview was conducted with CNA 2. CNA 2 stated she took Resident 5's blood pressure on her right arm. CNA 2 stated Resident 5's left arm was contracted. CNA 2 stated she was not aware Resident 5 had an AV fistula. On 8/2/19 at 1035 hours, an interview was conducted with the Dialysis RN. The Dialysis RN stated to avoid taking the blood pressure on the arm where the AV fistula was to prevent complications. The Dialysis RN stated possible complications will include ballooning and rupture of the fistula. c. Review of the Dialysis Communication Records dated 7/26/19, 7/24/19, 7/22/19, and 7/10/19, showed Resident 5 was not assessed when she came back after dialysis. On 7/30/19 at 0940 hours, an interview was conducted with RN 3. RN 3 stated the licensed nurses had to assess Resident 5 before and after dialysis. RN 3 stated the licensed nurses had to document the assessment on the Dialysis Communication Records. RN 3 verified Resident 5 was not assessed when she came back to the facility after dialysis. RN 3 acknowledged the post dialysis assessment had to be done to ensure Resident 5 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 46 of 77 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 08/05/2019 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 medically stable after the procedure. RN 3 stated the post dialysis assessment would detect any possible complications from dialysis, such as changes in Resident 5's blood pressure. 2. Review of the facility's P&P titled Medication Administration General Guidelines (undated) showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. It also showed if two consecutive doses of a vital medication are withheld or refused, the physician is notified. Medical record review for Resident 132 was initiated on 7/29/19. Resident 132 was readmitted to the facility on 7/26/18, with diagnoses including end stage renal disease, requiring dialysis. Review of the Order Summary Report dated 6/27/19, showed Resident 132 was to receive dialysis every Monday, Wednesday, and Friday at a dialysis center, with a scheduled appointment from 1015 - 1445 hours. The physician's orders also showed to administer amlodipine besylate (antihypertensive) 10 mg one tablet by mouth at 0900 hours, carvedilol (antihypertensive) 25 mg one tablet by mouth at 0900 and 1700 hours, minoxidil (antihypertensive) 2.5 mg one tablet by mouth at 0900 and 1700 hours, and Renvela (used to lower phosphorus levels in patients who are on dialysis due to kidney disease) 800 mg four tablets with meals at 0700, 1200, and 1700 hours. Review of Resident 132's Medication Administration Record dated 7/1 to 7/31/19, showed medications with chart code "2" documented meant the medication was held and see nurses' notes. It also showed medications with chart code "8" documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 47 of 77 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 08/05/2019 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 meant the resident was absent from the facility. Resident 132's Medication Administration Record for July 2019 showed the resident's above medications were held six to 10 times. On 7/30/19 at 1448 hours, an interview and concurrent medical record was conducted with LVN 1. LVN 1 was asked what the chart codes "2" and "8" on the Medication Administration Record meant. LVN 1 stated chart codes 2 and 8 meant the resident was out to dialysis and the medications were not administered. When LVN 1 was asked if there was a physician's order to hold the medications when Resident 132 was out for dialysis, LVN 1 stated no. LVN 1 verified there was no order found in Resident 132's medical record to hold the medications when the resident was out for dialysis. On 7/30/19 at 1530 hours, the DON was informed and acknowledged the above findings.

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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 48 of 77 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 08/05/2019 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) 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. §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 a routine controlled medication was available for one of 28 final sampled residents (Resident 112). This failure resulted in Resident 112 not being administered three doses of her routine narcotic pain medication as per the physician's order. Findings: Review of the facility's P&P titled Medication Administration Guidelines (undated) showed the procedure for ordering schedule II controlled substance medications was to reorder the medication when a seven-day supply remains to allow for preparing and dispensing of the prescription. On 7/30/19 at 1105 hours, an interview was conducted with Resident 112. Resident 112 stated the facility ran out of her pain medication for two days. Resident 112 stated her pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 49 of 77 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 08/05/2019 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 level without the medication was 8 out of 10 (on a pain scale of 0 to 10 with 0 = no pain to 10 = severe pain). Medical record review for Resident 112 was initiated on 7/30/19. Resident 112 was admitted to the facility on 7/27/18. Review of the Order Summary Report showed a physician's order dated 5/2/19, for methadone hydrochloride (narcotic pain medication) 10 mg one tablet by mouth two times a day for pain management. Review of the Medication Administration Record for July 2019 showed the methadone hydrochloride 10 mg tablet was scheduled to be given daily at 0600 and 1800 hours. However, the medication was not administered on 7/28/19 at 0600 hours, and on 7/29/19 at 0600 and 1800 hours. Resident 112 missed three doses of the pain medication. On 8/1/19 at 1530 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 reviewed the medical record and verified Resident 112 was not administered the methadone hydrochloride tablets on 7/28/19 at 0600 hours, and on 7/29/19 at 0600 and 1800 hours, because they were not available. LVN 9 stated the medication should have been requested before they ran out, and she requested for a refill of the methadone hydrochloride tablet from the pharmacy on 7/29/19 at 1945 hours.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 50 of 77 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 08/05/2019 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 is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to provide adequate monitoring of medication for one nonsampled resident (Resident 7). Resident 7 was receiving a blood pressure medication without documented blood pressure monitoring, and without blood pressure parameters when to hold or give the medication. This had the potential for the resident to receive an unnecessary medication and developing significant side effects. Findings: Medical record review for Resident 7 was initiated on 8/1/19. Resident 7 was admitted to the facility on 2/17/17. Review of the Order Summary Report showed a physician's order dated 5/1/19, for amlodipine besylate (blood pressure medication) 5 mg one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 51 of 77 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 08/05/2019 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 tablet by mouth once a day for hypertension. There was no parameter when to give or hold the medication. Review of the Medication Administration Record for July 2019 failed to show Resident 7's blood pressure was monitored before the amlodipine besylate was administered. On 8/1/19 at 1547 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 reviewed the medical record and verified Resident 7's blood pressure was not monitored, and there were no parameters documented as to when to hold or give the amlodipine besylate tablet. RN 3 stated the blood pressure needed to be checked and the parameters were needed.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 10/10/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 52 of 77 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 08/05/2019 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 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 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: 4. According to the third edition of Taylor's Clinical Nursing Skills, orthostatic hypotension was defined as a drop of at least 20 mm Hg systolic or 10 mmHg diastolic in blood pressure within three minutes of quiet standing after being supine (laying down). To assess for orthostatic hypotension follow the following guidelines: - Ask the patient to lie in a supine position (on their back) for 3-10 minutes, then take the initial blood pressure and pulse measurements. - Assist the patient to a sitting position on the side of the bed with the legs dangling. After 1-3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 53 of 77 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 08/05/2019 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 minutes, take the blood pressure and pulse measurements. - Assist the patient to stand (unless contraindicated) and wait for 2-3 minutes. Take the blood pressure and pulse measurements. - Record the measurements for each position while noting the position with the readings. An increase of 40 beats in the pulse rate or a decrease in blood pressure of 30 mmHg is abnormal. Review of Resident 20's medical record was initiated on 7/29/19. Resident 20 was admitted to the facility on 2/1/18. Review of the Order Summary Report dated 6/27/19, showed Resident 20 had an order dated 6/18/19, to administer quetiapine fumarate (Seroquel, an antipsychotic medication) 6.25 mg by mouth at bedtime for psychosis manifested by sudden outbursts and constant yelling. An order dated 5/1/19, showed to monitor Resident 20's orthostatic blood pressure every week on Sundays for Seroquel. Review of the Medication Administration Records dated June and July 2019 showed Resident 20 had one blood pressure measurement for orthostatic hypotension. Examples of Resident 20's blood pressure readings were as follows: - On 6/2/19, the BP was 135/76 mmHg. - On 6/9/19, the BP was 124/78 mmHg. - On 6/16/19, the BP was 160/52 mmHg. - On 6/23/19, the BP was 141/76 mmHg. - On 7/7/19, the BP was 144/70 mmHg. - On 7/14/19, the BP was 133/86 mmHg. - On 7/21/19, the BP was 124/62 mmHg. - On 7/28/19, the BP was 128/77 mmHg. On 8/1/19 at 1459 hours, an interview was conducted with LVN 3. LVN 3 stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 54 of 77 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 08/05/2019 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 20 was monitored for orthostatic hypotension. LVN 3 stated he took Resident 20's blood pressure when he was in the lying, sitting, and standing positions. LVN 3 stated orthostatic hypotension was a drop in Resident 20's blood pressure when he changed positions. LVN 3 stated he was not sure how much of the blood pressure drop would be considered orthostatic hypotension. LVN 3 verified there was only one blood pressure reading for Resident 20. LVN 3 stated the blood pressures taken while Resident 20 assumed different positions had to be assessed and documented. LVN 3 stated it was necessary to monitor Resident 20 for orthostatic hypotension as an adverse effect of his antipsychotic medication. On 8/1/19 at 1518 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 stated orthostatic hypotension was an adverse effect of antipsychotic medications. RN 3 stated, to assess for orthostatic hypotension, the resident's blood pressure had to be taken from lying to sitting and sitting to standing positions. RN 3 stated orthostatic hypotension was a drop in the systolic blood pressure of 20 mmHg when moving from one position to another. RN 3 verified Resident 20's orthostatic blood pressure monitoring was not accurate since only one blood pressure measurement was assessed and documented. RN 3 stated the blood pressure readings from different positions had to be assessed and documented. Based on interview and medical record review, the facility failed to ensure four of 28 final sampled residents (Residents 20, 35, 76, and 142) were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 76's and Resident 35's orthostatic blood pressures FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 55 of 77 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 08/05/2019 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 (measure the blood pressure while laying down or sitting and again upon standing up) were monitored as ordered by the physicians related to the use of an antipsychotic medication. * The facility failed to ensure the as needed orders for psychotropic drugs for Residents 76 and 142 were limited to 14 days or had a documented rationale from the physicians for the appropriateness of extending the PRN (as needed) orders beyond 14 days. * The facility failed to ensure Resident 20's blood pressure was assessed accurately to determine the adverse effect of orthostatic hypotension from Seroquel (antipsychotic) use. These failures had the potential for the residents to experience adverse consequences from the psychotropic medications. Findings: 1. Medical record review for Resident 35 was initiated on 7/29/19. Resident 35 was readmitted to the facility on 11/9/14. Review of the Order Summary Report showed a physician's order dated 6/20/19, for Seroquel 75 mg, by mouth, three times a day for anxiety manifested by agitation; and an order dated 7/22/19, to monitor Resident 35's orthostatic blood pressure every Tuesday, on the day shift, related to the use of Seroquel. Review of the Medication Administration Record for July 2019 showed the orthostatic blood pressure was scheduled to be monitored on 7/23 and 7/30/19. However, there was only one blood pressure reading documented for each date. On 8/1/19 at 1556 hours, an interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 56 of 77 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 08/05/2019 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 concurrent medical record review was conducted with LVN 5. LVN 5 was asked how to obtain the orthostatic blood pressure readings. LVN 5 stated Resident 35 was unable to stand up, so the resident's orthostatic blood pressures would be obtained with the resident lying down and again when sitting up. LVN 5 verified Resident 35's orthostatic blood pressure was inaccurately monitored and stated there should be two blood pressure readings documented in the Medication Administration Record. 2. Medical record review for Resident 76 was initiated on 7/29/19. Resident 76 was admitted to the facility on 4/26/18. Review of the Order Summary Report showed a physician's order dated 5/1/19, for clonazepam (antianxiety medication) 1 mg, give one tablet by mouth, every six hours as needed for anxiety. The order did not have a stop date. Review of the medical record, failed to show the physician or prescribing practitioner documented a rationale for the appropriateness of extending the as needed order for alprazolam beyond 14 days. On 7/30/19 at 1110 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 reviewed the medical record and verified the above findings. LVN 6 stated the order needed to be clarified. 3. Medical record review for Resident 142 was initiated on 8/1/19. Resident 142 was admitted to the facility on 2/1/16. Review of Resident 142's physician telephone order dated 7/29/19, showed an order for lorazepam (antianxiety medication) concentrate 2 mg per ml, give 0.25 ml sublingually every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 57 of 77 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 08/05/2019 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 four hours as needed for anxiety manifested by yelling. On 8/1/19 at 1150 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 142's physician telephone order dated 7/29/19, for lorazepam as needed for anxiety should have a stop date of 14 days. The DON verified the finding.

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 28 sampled residents (Resident 126) and three nonsampled residents (Residents 1, 7, and 15) were free from significant medication errors. * The facility failed to ensure Resident 7 received her routine medications including the antihypertensive, antianxiety, and narcotic pain medications in a timely manner. As a result, Resident 7 experienced a lot of pain, anxiety, and was not able to participate in the afternoon group activities, which she loved to do in the afternoon. In addition, the licensed nurse who administered Resident 7's medications late, did not inform the oncoming licensed nurse about the delay in the medication administration, resulting in duplicate medication administration with less than a 10 minutes interval. * Resident 126 did not receive his Lantus insulin (antidiabetic medication) injection on 7/30/19 at 2100 hours. RN 5 was running FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 58 of 77 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 08/05/2019 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 behind with her medication pass and did not get to Resident 126 until 2300 hours. Resident 126 was asleep, so RN 5 documented Resident 126 refused the Lantus insulin injection. As a result, Resident 126 had a hyperglycemia episode the following morning, requiring the insulin coverage. In addition, on 7/29/19, RN 5 was running behind with her medication pass and could not take Resident 126's blood pressure, so Resident 126 refused to take the blood pressure medications. * Resident 1 was not administered her medications as ordered by the physician and as scheduled. * Resident 15 was administered her pain medication from another resident's medication supply. Findings: 1. On 7/29/19 at 0913 hours, an interview was conducted with Resident 7. Resident 7 brought up a concern of not getting her medications in a timely manner when nurses from the registry agency were working. Medical record review for Resident 7 was initiated on 8/1/19. Resident 7 was admitted to the facility on 2/17/17. Review of the annual MDS dated 7/13/19, showed Resident 7 had no cognitive impairment. Review of the Medication Administration Record for July 2019 showed the following medications scheduled to be administered daily at 0900 hours: - duloxetine hydrochloride (antidepressant medication) delayed release capsule 40 mg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 59 of 77 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 08/05/2019 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 one capsule; - amlodipine besylate (blood pressure medication) 5 mg one tablet; - Glycolax (stool softener) powder 17 grams; and - omeprazole (medication for gastric ulcer or reflux) delayed release tablet 20 mg one tablet. Further review of the Medication Administration Record for July 2019 showed the following medications scheduled to be administered daily at 0900 and 1700 hours: - alprazolam (antianxiety medication) 0.25 mg one tablet; - docusate sodium (stool softener) 250 mg one capsule; - ferrousul (iron supplement) 325 mg one tablet; - hydroxychloroquine sulfate (medication for rheumatoid arthritis) 200 mg one tablet; - saccharomyces boulardii (probiotic) 250 mg one capsule; and - vitamin D3 tablet 1000 iu one tablet. Further review of the Medication Administration Record for July 2019 showed Norco (narcotic pain medication) 5-325 mg one tablet was scheduled to be administered daily at 0600, 1200, 1800 and 2400 hours. On 8/1/19 at 1335 hours, a follow-up interview was conducted with Resident 7. Resident 7 stated she did not receive her 0900 hours routine medications and 1200 hours pain pill until later in the evening on 7/28/19. Resident 7 stated she was in a lot of pain so she asked the licensed nurse multiple times for her pain pill. Resident 7 stated the licensed nurse repeatedly told her " ...she could not find it in the system." Resident 7 stated she was in a lot of pain due to her broken vertebrae. Resident 7 stated she missed going to the afternoon FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 60 of 77 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 08/05/2019 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 activities that day because of her pain. Resident 7 stated, " ...I was so upset that day. I was miserable." Review of the LN - Pain Management Review dated 7/20/19, showed Resident 7 experienced back pain daily or several times a day. The assessment showed Resident 7's pain was worst at mid-morning and the afternoon; and the pain could affect Resident 7's therapy or activities of choice, and her ability to bathe, groom and dress self. The medication that relieved her pain in the past was the Norco tablet. Review of the Activity - Annual Evaluation dated 7/15/19, showed Resident 7 enjoyed participating in all kinds of activities in the afternoon. Review of the One-to-One Activity Participation Documentation for July 2019 showed Resident 7 refused an activity invite on 7/28/19. Review of the Medication Administration Audit Report (showing the actual administration and documentation times for each medications administered to the resident) for 7/28/19, showed all medications scheduled to be given to Resident 7 at 0900 and 1200 hours were administered at 1829 and 1830 hours. However, further review of the Medication Administration Audit Report for 7/28/19, showed the medications scheduled to be administered at 1700 hours to Resident 7 were all administered at 1838 hours. Resident 7 received duplicate medications, including the alprazolam 0.25 mg tablet and Norco 5-325 mg tablet in eight and nine minutes intervals. Review of the Controlled Drug/Receipt/Record/Disposition Form for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 61 of 77 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 08/05/2019 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 alprazolam 0.25 mg tablet showed two tablets were taken on 7/28/19 at 0900 and 1700 hours. Review of the Controlled Drug/Receipt/Record/Disposition Form for the Norco 5-325 mg tablet showed four tablets were taken on 7/28/19 at 0000, 0600, 1200, and 1800 hours. Review of the medical record failed to show Resident 7's physician was notified of the delay in the medication administration. On 8/1/19 at 1547 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 reviewed the medical record and verified the above findings. RN 3 stated she could not find any documentation the physician was informed of the delay in the administration of medications to Resident 7. RN 3 also verified Resident 7's blood pressure was not monitored on 7/28/19, when she was not administered her antihypertensive medication in a timely manner. Cross reference to F684, example #2. On 8/5/19 at 1534 hours, a telephone interview was conducted with LVN 2. LVN 2 stated she worked the 1500 to 2300 hours shift on 7/28/19, and administered Resident 7's medications as scheduled. LVN 2 stated she did not receive any report from the outgoing licensed nurse (0700 to 1500 shift) regarding Resident 7's medications being administered late. 2. Medical record review for Resident 126 was initiated on 7/29/19. Resident 126 was admitted to the facility on 6/27/19. Review of the History and Physical Examination dated 6/28/19, showed Resident 126 had the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 62 of 77 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 08/05/2019 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 a. On 7/31/19 at 0945 hours, an interview was conducted with Resident 126. Resident 126 stated he did not receive his bedtime Lantus insulin injection last night (7/30/19). Resident 126 stated the Lantus insulin injection at bedtime was important for him because his blood sugar levels were not stable. Review of the Order Summary Report showed a physician's order dated 7/16/19, for Lantus Solostar solution pen-injector 100 unit/ml, inject 32 units subcutaneously (under the skin) at bedtime for diabetes mellitus. The Lantus insulin injection was increased from 20 units to 32 units on 7/16/19, due to high blood sugar levels. Review of the Medication Administration Record for July 2019 showed the Lantus insulin injection was scheduled to be administered daily at 2100 hours. On 7/30/19, RN 5 documented the medication was not administered because Resident 126 refused the Lantus insulin injection. Further review showed Resident 126's blood sugar level on 7/30/19 at 1630 hours was 305 mg/dl, and the resident was administered four units of insulin injection per sliding scale (the dose of insulin based on the resident's blood sugar level). Resident 126's blood sugar levels had been unstable ranging from 82-500 mg/dl from 7/1 to 7/31/19. Resident 127's blood sugar level at 0630 hours the past week (7/24 to 7/30/19) had been stable at 88 to 169 mg/dl when he received his Lantus insulin injection the night before. However, on 7/31/19 at 0630 hours, Resident 126's blood sugar level was 249 mg/dl, when he did not receive his Lantus insulin injection the night before. On 7/31/19 at 1330 and 1500 hours, an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 63 of 77 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 08/05/2019 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 interview and concurrent medical record review was conducted with RN 5. RN 5 reviewed the medical record and verified the above findings. RN 5 stated she was running behind with her medication pass and when she got in to Resident 126's room he was already asleep, so she documented Resident 126 refused the Lantus injection. b. Review of the Order Summary Report showed a physician's orders dated: - 6/27/19, for amlodipine besylate (blood pressure medication) 10 mg one tablet by mouth once a day; and - 7/22/19, for losartan potassium tablet 25 mg one tablet by mouth once a day. Review of the Medication Administration Record for July 2019 showed the amlodipine 10 mg tablet and losartan potassium 25 mg tablet were scheduled to be given daily at 0900 hours. However, on 7/29/19, the documentation showed Resident 126 refused both blood pressure medications. Review of the Blood Pressure Summary showed Resident 126's blood pressure were not monitored from 7/28 to 7/30/19. On 7/31/19 at 0804 hours, Resident 126's blood pressure reading was 162/100 mmHg. On 7/31/19 at 1000 hours, an interview was conducted with Resident 126. Resident 126 stated he refused the blood pressure medications because RN 5 did not take his blood pressure before administering the medications. On 7/31/19 at 1330 hours, an interview was conducted with RN 5. RN 5 stated she worked the 0700 to 1500 shift on 7/29/19. RN 5 verified the above findings and stated she did not take Resident 126's blood pressure and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 64 of 77 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 08/05/2019 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 heart rate on 7/29/19, because she was running behind with her medication pass. 3. Review of the facility's P&P titled Medication Administration Guidelines (undated) showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The medications supplied for one resident are never administered to another resident. a. On 7/29/19 at 1437 hours, a Resident Council meeting was conducted with the residents. Resident 1 verbalized she did not receive all her morning medications. Medical record review for Resident 1 was initiated on 7/29/19. Resident 1 was admitted to the facility on 4/13/15, and readmitted on 5/8/19. Review of Resident 1's Order Summary Report dated 6/27/19, showed the resident was to receive the following medications: * allopurinol tablet 100 mg one tablet by mouth at 0900 hours, * aspirin tablet 81 mg one tablet by mouth at 0900 hours, * fludrocortisone acetate tablet 0.1 mg one tablet by by mouth at 1200 hours, * polyethelene glycol 3350, 17 gm by mouth at 0900 hours, * oxybutynin chloride tablet 5 mg two tablets by mouth at 0900 hours, * saccharomyces boulardii capsule 250 mg two capsules by mouth at 0900 hours, * docusate sodium capsule 250 mg one capsule at 0900 and 2100 hours, * hydroxyurea capsule 500 mg one capsule at 0900 and 1700 hours, * calcium carbonate tablet chewable 500 mg one tablet at 0630, 1130, and 1630 hours, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 65 of 77 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 08/05/2019 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 * midodrine hcl tablet 10 mg one tablet at 0600, 1400, and 2200 hours, and * metoclopramide tablet 10 mg one tablet at 0630, 1130, 1630, and 2000 hours. Review of Resident 1's Medication Admin Audit Report dated 7/31/19, showed the Resident 1's medication administration times for the following medications administered on 7/29/19 were as follows: * calcium carbonate tablet chewable 500 mg, administered at 1703 and 1731 hours * metoclopramide hcl 10 mg, administered at 1703 and 1731 hours * hydroxyurea capsule 500 mg, administered at 1703 and 1747 hours, and * trauma hcl 50 mg, administered at 1703 and 1749 hours On 7/29/19 at 1639 hours, the DON was informed and acknowledged the above findings. The DON stated RN 4 should have taken Resident 1 ensured Resident 1's medications were administered on time. On 7/29/19 at 1648 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 4. RN 4 stated she did not administer Resident 1's morning medications as scheduled because the resident was in the activity room throughout her shift. She stated she was told she could not administer the residents' medications when they were in the activity room. RN 4 verified Resident 1's morning medications were administered late. 4. On 7/31/19 at 1524 hours, a narcotic count verification for Medication Cart #5 was conducted with LVN 1. Review of Resident 15's oxycodone hcl 15 mg bubble pack identified the count did not match. The number FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 66 of 77 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 08/05/2019 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 of pills in the bubble pack compared to the resident's Controlled Drug Receipt/Record/Disposition Form showed one tablet was unaccounted for. LVN 1 was asked about discrepancy. LVN 1 stated she used one tablet of Resident 94's oxycodone hcl 15 mg to administer to Resident 15 because Resident 15's oxycodone hcl ER 15 mg supply had ran out. LVN 1 stated she should have told the resident she had to hold the medication because the pharmacy had not delivered it yet. Review of Resident 15's Order Summary Report dated 6/27/19, showed the resident was supposed to get oxycodone hcl ER 15 mg one tablet by mouth once a day, not oxycodone hcl 15 mg. On 7/31/19 at 1555 hours, the DON was informed and acknowledged the above findings. The DON stated LVN 1 should have obtained the oxycodone hcl ER 15 mg from the facility's emergency medication kit instead of getting it from another resident's medication supply. On 7/31/19 at 1628 hours, Resident 15 was observed in bed lying on her back watching a television program. The resident was asked by CNA 11 in their native language how she was feeling and if she was experiencing pain at this time. Resident 15 stated no.

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 §483.60(d) Food and drink Each resident receives and the facility providesFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 67 of 77 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 08/05/2019 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(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences and physician's orders for food texture was honored for one of 28 final sampled residents (Resident 51). The facility also failed to ensure substitutes were offered of equal nutritive value. * Resident 51 was served whole kernel corn instead of creamed corn for residents on a mechanical soft diet. Resident 51 was not offered a meal substitute of equal nutritive value when the resident was observed not eating her lunch. Resident 51 was not served 8 ounces of milk 2% as part of her standing order for lunch. These deficient practices put the resident at risk of unintended weight loss as a result of the food not meeting their nutritional needs. Findings: During the dining observation on 7/29/19 at 1220 hours, Resident 51 was observed being served chopped potato, chopped Salisbury steak, whole kernel corn and 8 ounces of apple juice. Resident 51 was observed not eating the food on her lunch tray. RNA 1 was asked if the facility had food substitutes to provide to residents who did not like the food being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 68 of 77 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 08/05/2019 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 served. RNA 1 stated the facility usually provided a turkey sandwich as a meal substitute. However, Resident 51 was not observed being offered a substitute. Review of Resident 51's meal card for lunch (undated) showed the resident was on a mechanical soft, chopped, fortified diet with a standing order for 8 ounces of 2% milk. No milk was observed being served to Resident 51 on her lunch tray. Review of the facility's Summer Menus for 7/1, 7/29, and 8/26/19, showed creamed corn was to be served to residents on a mechanical soft diet. However, the corn served to Resident 51 on her lunch tray was whole kernel corn, not creamed. Review of Resident 51's plan of care showed a care plan problem with a revision dated 7/3/19, addressing the resident's nutritional risk for unintended weight loss. The Interventions included, if the resident eats less than 75%, offer a meal replacement. On 7/29/19 at 1235 hours, an interview was conducted with the RD. The RD verified Resident 51 was served whole kernel corn for lunch. On 8/1/19 at 1443 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS was asked what food substitutes were available for the residents when they did not like the food served. The DSS stated the facility's meal alternatives a included ham or turkey sandwich with mustard and mayonnaise, a peanut butter and jelly sandwich on whole wheat, a fruit plate with cottage cheese, a cheese quesadilla with fresh salsa or a chef's salad with dressing. The DSS was informed Resident 51 was not offered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 69 of 77 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 08/05/2019 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 a meal substitute on 7/29/19 during lunch. The DSS was asked what did a standing order mean on a resident's meal card. The DSS stated it meant 8 ounces of 2% milk should be given at every meal. The DSS was informed Resident 15 was not served the 8 ounces of 2% milk at lunch on 7/29/19. The DSS acknowledged the above findings.

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

F812 10/02/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain a sanitary environment in the dietary department. * The facility failed to ensure the opened and prepared food items were labeled and dated. The facility failed to ensure the dry storage and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 70 of 77 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 08/05/2019 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 walk in refrigerator were free of expired items. The facility failed to ensure fluorescent light bulbs were covered above the food preparation area. In addition, the facility failed to ensure the kitchen was free of a personal item. * The facility failed to ensure food stored in the walk-in refrigerator was not being contaminated by water leaking from the refrigerator condenser. * The facility failed to ensure there was an air gap in the drains for the walk in refrigerator and the juice concentrator machine. * The facility failed to ensure the dietary staff observed proper hand hygiene. * The facility failed to ensure the kitchen was free of broken and missing floor tiles. These failures posed the risk of negatively impacting safe food handling for the residents. Findings: Review of the Form CMS-672 Resident Census and Conditions of Residents completed by the DON and dated 7/29/19, showed 129 of the 143 residents received meals from the kitchen. 1. On 7/29/19, beginning at 0745 hours, an initial tour was conducted with the DSS. The DSS verified the following observations and findings. a. Observation of the walk in refrigerator identified the following: - A pack of Mandarin orange sauce was unlabeled and undated; - Nine small bowls of vegetable salad were unlabeled and undated; - A bag of vegetable salad mix had an opened FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 71 of 77 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 08/05/2019 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 date of 7/18/19. The DSS stated the shelf life of the salad was only three days; - A container of turkey slices had an opened date of 7/21/19, but with no best/use by date. The DSS stated the turkey slices were only good for three days; - A second container of turkey slices had an expiration of 7/22/19; - A plastic bag with half a roll of ham had an opened date of 7/28/19, but with no best/use by date; - A clear container with snacks (shakes, pudding, yogurt) covered with a clear plastic was dated 7/26/19. The DSS stated the container should have been served on 7/26/19, and expired the same day. b. Observation of the food preparation area identified the following: - A clear container of white cream in the food preparation area was unlabeled and undated; - A vegetable peeler with food debris was hanging on the faucet; - A lanyard with a set of keys was observed next to containers of spices. The DSS stated personal items should not be in the spice rack; - Two fluorescent light bulbs were observed with no cover. The DSS stated the lights should be covered; - Dust and food debris were observed behind the food preparation counter and stove. c. Observation of the dry storage area showed an opened bag of cinnamon raisin bread with a best buy date of 5/10/19. The DSS acknowledged food had to be labeled and dated for safe consumption. The DSS stated expired food should be thrown out as soon as they expire and the kitchen should be free from debris and dust to prevent contamination. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 72 of 77 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 08/05/2019 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. According to the USDA Food Code 2017, 3305.11 Food Storage, food shall be protected from contamination by storing the food in a clean, dry location, where it is not exposed to splash, dust, or other contamination. During the initial tour of the kitchen on 7/29/19 at 0745 hours, an observation of the kitchen's walk in refrigerator was conducted with the DSS. The ceiling in the walk-in refrigerator was observed leaking water. The water was observed dripping into a green plastic tray placed on the shelf below the leak. The DSS stated the condenser unit had been leaking for a few weeks and the maintenance staff knew about it. Underneath the leaking ceiling, five bags of bread and a box of cucumbers were observed sitting in a tray with about half an inch of water in it. On 8/1/19 at 1420 hours, an observation and concurrent interview with the DSS was conducted in the walk in refrigerator. The ceiling of the walk in refrigerator was still leaking. Underneath the leaking ceiling, a stainless steel pan was observed with an open container of strawberries. 3. According to the USDA Food Code 2017, Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). a. On 7/29/19, beginning at 0745 hours, during the initial tour of the kitchen, a pipe was observed coming out of the wall beside the walk in refrigerator door. The pipe extended inside the drain and no air gap was observed. The DSS stated the pipe was to drain water from the walk in refrigerator condenser. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 73 of 77 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 08/05/2019 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 7/30/19 at 1031 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated he raised the pipe to maintain an air gap. The Maintenance Director stated the air gap prevented water from the drain entering the refrigerator condenser. b. On 7/29/19, beginning at 0745 hours, during the initial tour of the kitchen, a white tube was observed coming out of the juice concentrator machine and extended inside the drain, with no air gap. The DSS stated the tube was to drain condensation from the juice machine. On 7/30/19 at 1031 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the drain needed to have an air gap. The Maintenance Director stated when water overflows from the drain, the water could enter the tube and affect how the machine functions. 4. According to the USDA Food Code 2017, Section 2-301.14, When to Wash, food employees shall clean their hands after handling soiled equipment or utensils. On 7/31/19 at 0845 hours, an observation and concurrent interview was conducted with Dietary Aide 1. Dietary Aide 1 was rinsing off dirty plates, plate covers and bowls on the dirty side of the dishwashing area. Without performing hand hygiene, Dietary Aide 1 went to the clean side of the dishwashing area and touched clean pink pitchers and clean pink trays. Dietary Aide 1 verified she did not perform proper hand hygiene after handling soiled items. On 7/31/19 at 0850 hours, an interview was conducted with the DSS. The DSS stated staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 74 of 77 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 08/05/2019 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 should wash their hands when going from the dirty side to the clean side of the dishwashing area. 5. On 7/31/19 at 0929 hours, an observation and concurrent interview was conducted with the DSS. The tiles under the three compartment sink were observed missing and broken and there was a pool of dirty water. The DSS stated the missing and broken tiles should be repaired to prevent pooling of water.

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 include, but are not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 75 of 77 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 08/05/2019 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) 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: Based on observation and interview, the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 76 of 77 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 08/05/2019 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 failed to ensure the porous padding on four of four beds with side rails (Rooms A, B, C, and D) were free from frays, tears, and holes and uncleanable surfaces. This failure had the potential to cause the growth and spread of bacteria. Findings: On 7/30/19 at 1058 hours, an observation and concurrent interview was conducted with the Maintenance Director. The following rooms were observed to have padded side rails. The padding on the side rails was porous with tears, holes, and fraying edges. * Room A's side rails were observed to be torn and frayed, with holes. * Room B's side rails were observed to be torn and with holes. * Room C's side rails were observed with holes. * Room D's side rails were observed to be torn and with holes. The Maintenance Director stated the pads on the side rails were insulation purchased from a home repair/improvement store. The Maintenance Director stated the pads were made of porous material. The Maintenance Director stated the padded side rails were cleaned daily by housekeeping with bleach wipes. When asked to show the bottle of the cleaner, the directions on the label showed to apply the product by wiping the nonporous, hard surface to thoroughly wet it. When shown the directions on the label of the cleaner showed it was to be used on nonporous surfaces, the Maintenance Director verified the padding could not be cleaned and stated they needed to be replaced right now. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQNZ11 Facility ID: CA060000094 If continuation sheet 77 of 77