Other·July 17, 2020

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 an EXTENDED ABBREVIATED survey to investigate Facility Reported Incident (FRI) No.: CA00676666. Inspection was limited to the specific FRI investigated and did not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 41418, HFEN; Surveyor 38492, HFEN; Surveyor 41231, HFEN; and Surveyor 39210, HFEN. THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE FRI. FINDINGS WERE CITED AT F600, F609, AND F610 FOR RESIDENTS 1 AND 3; F550 AND F610 FOR RESIDENT 2; AND F607. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADON - Assistant Director of Nursing CNA - Certified Nursing Assistant DON - Director of Nursing IJ - immediate jeopardy LVN - Licensed Vocational Nurse perineal- the space between the anus and scrotum P&P - policy and procedure RN- Registered Nurse ROM - range of motion On 2/20/2020 at 0839 hours, the facility was informed the IJ was identified as evidenced by the following deficient practices: * The facility failed to thoroughly investigate and report the abuse when Residents 1 and 3 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: AUOR11 Facility ID: CA060000094 If continuation sheet 1 of 26 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 02/27/2020 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 were found physically restrained. Resident 1 had a blanket wrapped tightly (like a mummy) around his upper shoulders, arms, and extending down to his thigh. Both Residents 1 and 3 had their hospital gowns tied to purposely restrict the residents' movement and access to their bodies. * The facility failed to protect the residents from further abuse when Resident 3 was observed a second time in bed with her gown tucked tightly underneath her body, restricting access to her body. On 2/22/2020 at 1641 hours, the IJ was abated after the facility had implemented the following plan of corrective actions: * Initiated an investigation and suspended the identified staff pending the outcome of the investigation. * Interviewed all alert residents regarding abuse and restraints. * Conducted the head to toe assessments for Residents 1 and 3 and placed them on monitoring for adverse effects. * Conducted facility tour rounds on all shifts to ensure no residents were physically restricted. * In-service all staff on the facility's P&Ps regarding abuse and restraints The facility provided documented evidence which showed the nursing, department management, maintenance, and housekeeping staff had been in-serviced on the facility's P&Ps for abuse and restraints. Cross reference to

F600. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 2 of 26 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 02/27/2020 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

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

F550 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 3 of 26 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 02/27/2020 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 exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure care was provided in a manner promoting the dignity and respect for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 was fully informed of the care being provided by CNA 22. CNA 22 checked Resident 2's diaper without informing and asking Resident 2 for permission. This failure had resulted in Resident 2 feeling uneasy and violated. Findings: On 2/19/2020 at 1121 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed in bed, awake. A urinary drainage bag was observed hanging from Resident 2's left side of the bed covered with a privacy bag. Resident 2 stated he woke up with CNA 22's hand inside his incontinence brief. When asked, Resident 2 could not recall the day the incident occurred; however, Resident 2 recalled the incident happened a few days ago. Resident 2 denied CNA 22 was grabbing or stroking his crotch area or any part of his body. Resident 2 stated it felt like CNA 22 was checking his diaper. Resident 2 stated he did not understand why CNA 22 had to check his diaper without talking to him first. Resident 2 stated he felt violated and uneasy. On 2/24/2020 at 1030 hours, a telephone interview was conducted with CNA 22. CNA 22 verified he worked on 2/12/2020. CNA 22 was asked regarding Resident 2. CNA 22 stated he tried to wake Resident 2 up to check if his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 4 of 26 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 02/27/2020 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 diaper was wet from a leaking urinary catheter and for a bowel movement. According to CNA 22, Resident 2 did not wake up. CNA 22 stated he proceeded to check Resident 2's diaper by placing his hand in Resident 2's diaper without informing or asking permission from Resident 2. CNA 22 stated, "...it was my bad" for not asking Resident 2 for permission before rendering care.

F600 SS=J Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of three sampled residents (Residents 1 and 3) were free from abuse. * Resident 1 was found with a bed sheet tightly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 5 of 26 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 02/27/2020 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 wrapped around his body to purposely restrict movement of his arms and preventing him from eating breakfast. * Resident 3 was found on two separate occasions with her gown tied in a knot to purposely restrict access to her body. These failures had the potential to cause serious injury and physical and/or psychosocial harm to the residents. On 2/20/2020 at 0839 hours, the facility was informed the IJ was identified as evidenced by the following deficient practices: * The facility failed to thoroughly investigate and report the abuse when Residents 1 and 3 were found physically restrained. Resident 1 had a blanket wrapped tightly (like a mummy) around his upper shoulders, arms, and extending down to his thigh. Both Residents 1 and 3 had their hospital gowns tied to purposely restrict the residents' movement and access to their bodies. * The facility failed to protect the residents from further abuse when Resident 3 was observed a second time in bed with her gown tucked tightly underneath her body, restricting access to her body. On 2/22/2020 at 1641 hours, the IJ was abated after the facility had implemented the following plan of corrective actions: * Initiated an investigation and suspended the identified staff pending the outcome of the investigation. * Interviewed all alert residents regarding abuse and restraints. * Conducted the head to toe assessments for Residents 1 and 3 and placed them on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 6 of 26 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 02/27/2020 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 monitoring for adverse effects. * Conducted facility tour rounds on all shifts to ensure no residents were physically restricted. * In-service all staff on the facility's P&Ps regarding abuse and restraints The facility provided documented evidence which showed the staff, including the nursing, department management, maintenance, and housekeeping staff had been in-serviced on the facility's P&Ps for abuse and restraints. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against dated 11/28/17, showed each resident has the right to be free from abuse. The facility will provide oversight and monitoring to ensure staff deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse. 1. Review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form which showed the facility had reported an allegation of physical abuse against Resident 1. Resident 1 was found with the bed sheets tightly wrapped around his body restricting the resident's movement of his arms. On 2/19/2020 at 1121 hours, an observation and concurrent interview with Resident 1 was conducted. Resident 1 was observed awake and lying in bed. Resident 1's gown was observed to be loose and could easily move all his extremities freely. Resident 1's upper and lower extremities were observed with no bruises or injuries. Resident 1 was asked if anyone had tied his gown around his legs before. Resident 1 stated he could not remember. Resident 1 was asked if anyone had tucked his bed linens tightly, restricting his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 7 of 26 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 02/27/2020 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 movement. Resident 1 did not respond. Medical Record review for Resident 1 was initiated on 2/19/2020. Resident 1 was admitted to the facility on 5/1/15. Review of Resident 1's MDS dated 5/20/19, showed Resident 1 had severely impaired cognition, required extensive one person assist for bed mobility (how resident moves in bed such as turning from side to side) and eating, and had no limitation in ROM functions on both upper and lower extremities. Review of Resident 1's eInteract Change in Condition Evaluation dated 2/15/2020, showed Resident 1 was found with his upper and lower extremities wrapped with a bed sheet. The document showed Resident 1 did not sustain any injuries from the incident. On 2/19/2020 at 1504 hours, a telephone interview was conducted with LVN 2. LVN 2 verified he worked on 2/15/2020 during the day shift (0700-1500 hours). LVN 2 stated he was familiar with Resident 1's care. LVN 2 was asked to describe the events that took place surrounding Resident 1 on 2/15/2020. LVN 2 stated at around 0910 hours he went into Resident 1's room to administer Resident 1's injectable medication. LVN 2 stated he noticed Resident 1 was lying in bed a blanket was loosely draped over the resident's body. LVN 2 stated he observed the resident's breakfast had been placed on the overbed table; however, the bedside table was not within the resident's reach and his breakfast was untouched. LVN 2 stated he prepared to administer Resident 1's medication by removing the blanket and when he did, he found Resident 1 "wrapped like a mummy" in another white blanket. LVN 2 stated a white blanket was wrapped around Resident 1's body FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 8 of 26 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 02/27/2020 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 multiple times. LVN 2 stated Resident 1 was wrapped from his shoulders to just above Resident 1's knees and his arms were wrapped inside the blanket. LVN 2 stated Resident 1 could not move his arms. LVN 2 stated he asked Resident 1 if he could move. LVN 2 stated Resident 1 said he was hungry but could not reach his breakfast tray. LVN 2 said he tried to remove the blanket from Resident 1's left shoulder and but was it was "hard to pull." LVN 2 stated he was able to partially free the resident left shoulder but had to ask for assistance from CNA 4. LVN 2 stated CNA 4 assisted him in unwrapping Resident 1 by turning the resident a few times and pulling at the blanket. LVN 2 added the blanket was "pretty tight." LVN 2 stated after they had freed the resident from the tightly wrapped blanket, he and CNA 4 then found the end of Resident 1's hospital gown tied and knotted together around the back of the resident's legs, just above his knees. LVN 2 stated he performed a body assessment and found no obvious injuries, bruises or trauma. LVN 2 stated he immediately reported the incident to RN 1. LVN 2 stated RN 1 interviewed Resident 1 and overheard Resident 1 say a lady during the night had wrapped him around in a blanket. LVN 2 stated he notified Resident 1's primary physician and family member of the incident. On 2/19/2020 at 1333 hours, an interview was conducted with CNA 4. CNA 4 verified she worked the day shift on 2/15/2020. CNA 4 stated she was familiar with Resident 1's care. CNA 4 was asked to describe the events that took place surrounding Resident 1 on 2/15/2020. CNA 4 stated she was called into Resident 1's room by LVN 2. CNA 4 stated she observed Resident 1 with a blanket tightly wrapped around his body. CNA 4 was asked what part of Resident 1's body was wrapped. CNA 4 stated the blanket was wrapped around FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 9 of 26 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 02/27/2020 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 1's shoulders, his arms and extended to just above his knees. CNA 4 described Resident 1 looked like he was "rolled in the blanket." CNA 4 stated, she and LVN 2 had to roll Resident 1 several times in order to remove the blanket. CNA 4 stated once the blanket was removed, Resident 1 was observed with the ends of the gown tied securely around his legs and knotted in the back behind his lower thigh area. CNA 4 stated Resident 1 could not move "at all." CNA 4 said she helped LVN 2 remove the knots from Resident 1's gown. On 2/19/2020 at 1441 hours, an interview was conducted with RN 1. RN 1 verified she worked the day shift on 2/15/2020, as the RN Supervisor. RN 1 was asked to describe the events that took place surrounding Resident 1 on 2/15/2020. RN 1 stated LVN 2 reported he found Resident 1's arms, legs, and body were rolled into a blanket, which prevented the resident from feeding himself. RN 1 stated she asked Resident 1 a few questions and the resident stated the incident happened during the night by a female CNA. The resident had stated the CNA had wrapped him in a blanket. RN 1 stated Resident 1 did not know the CNA's name. RN 1 stated she called the Administrator and reported the incident. Review of the facility's assignment sheet dated 2/14/2020, showed CNA 1 was assigned to Resident 1 the night shift (2300 to 0700 hours) of 2/14/2020. On 2/20/2020 at 0532 hours, an interview was conducted with CNA 1. CNA 1 verified she worked the night shift on 2/14/2020. CNA 1 was asked about Resident 1's care. CNA 1 stated Resident 1 was incontinent of bowel and he had behaviors of playing with his feces. CNA 1 was asked how often this behavior happened. CNA 1 stated, "every day." CNA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 10 of 26 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 02/27/2020 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 asked if the behavior was a new behavior and if the licensed nurses were aware. CNA 1 stated Resident 1's behavior was not new, it had been going on for a long time. CNA 1 said the licensed nurses should know of the behavior; however, CNA 1 could not confirm if the licensed nurses were aware of the resident's behavior. CNA 1 stated in order to keep Resident 1 from reaching into his briefs, she would tie the ends of his hospital gown around his legs. CNA 1 stated Resident 1 was able to remove the knotted gown and therefore, she wrapped Resident 1 "like a baby" to further prevent him from playing with his diaper. CNA 1 was asked to clarify how she wrapped Resident 1. CNA 1 stated she tightly wrapped a blanket around Resident 1's body from under his arms to right above his knees. When asked, CNA 1 denied wrapping Resident 1's arms inside the blanket. CNA 1 stated she had forgotten to remove the wrapped blanket and untie the knotted gown before the end of her shift. CNA 1 acknowledged she knew it was wrong, but she did it to keep Resident 1 and his environment clean from feces. CNA 1 stated she informed the Administrator she was responsible for Resident 1 being wrapped tightly in a blanket and having the ends of his gown tightly tied around his legs. Review of Resident 1's Allegation of AbuseInvestigation Report dated 2/20/2020, showed the investigation identified staff interviews on 2/15/2020. Documentation showed the staff interviewed included CNA 1. The document showed CNA 1 was asked if she had tucked Resident 1 tightly using a bed sheet; however, CNA 1 had denied having done so. The documentation showed CNA 1 stated she had tucked Resident 1's sheet around his lower extremities but denied tucking the sheet tight or wrapping him in it. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 11 of 26 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 02/27/2020 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 2/21/2020 at 1125 hours, a telephone interview was conducted with the Administrator. The Administrator stated he was informed of the alleged abuse against Resident 1 the morning of 2/15/2020. The Administrator stated RN 1 had informed him Resident 1 stated a female CNA had wrapped Resident 1 with a blanket. The Administrator stated he conducted the interviews with the staff the same day, however, stated he was unable to determine who the perpetrator was. The Administrator was asked if he changed any of the staff assignments or removed any staff from the care of Resident 1. The Administrator stated no, he had not. 2. Medical record review for Resident 3 was initiated on 2/19/2020. Resident 3 was readmitted to the facility on 3/12/11. Review of Resident 3's MDS dated 10/29/19, showed Resident 3 had moderately impaired cognition, required extensive one person assist for bed mobility, and had limitation in ROM functions on both lower extremities. Review of Resident 3's History and Physical Examination dated 2/3/2020, showed Resident 3 did not have the capacity to understand and make decisions. On 2/19/2020 at 1314 hours, an interview was conducted with CNA 3. CNA 3 stated she found Resident 3 with the ends of her gown tightly tied together around Resident 3's legs on 2/15/2020 around 0900 hours. CNA 3 stated the gown was tied so tightly it restricted the movement of Resident 3's legs. CNA 3 stated she immediately informed LVN 2 about what she found. CNA 3 stated Resident 3 was normally capable of moving her arms and legs, however she was weak. On 2/19/2020 at 1504 hours, a telephone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 12 of 26 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 02/27/2020 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 was conducted with LVN 2. LVN 2 stated CNA 3 informed him that she found Resident 3 with her gown tightly knotted on the morning of 2/15/2020. LVN 2 stated he observed the hospital gown tied in a double knot around the resident (this type of gown is normally open in the back to allow free movement of the person). LVN 2 stated he reported his findings to the Administrator on the same day (2/15/2020), and the Administrator told him it was not a concern and he did not consider it to be abuse. On 2/20/2020 at 0440 hours, an observation and concurrent interview was conducted with CNA 2 at Resident 3's bedside. Resident 3 was observed awake, lying in bed, and had a blanket covering her from her chest to her legs. CNA 2 was asked to remove Resident 3's cover. When CNA 3 removed the cover, Resident 3 was observed with the bottom of her gown tucked tightly underneath the back of of both of the resident's thighs. The position of the gown was in such a manner that the resident could not have done this herself. CNA 2 was observed to pull Resident 3's gown with force in order to loosen it from underneath the weight of the resident's body. CNA 2 was asked if Resident 3's hospital gown was knotted, and he stated no. CNA 2 stated he did not knot Resident 3's gown, he only tucked it in tightly underneath the resident in order to keep her from reaching into her incontinence brief and playing with her feces. On 2/20/2020 at 0548 hours, an interview was conducted with CNA 1. CNA 1 was asked about Resident 3. CNA 1 stated Resident 3 needed to be changed and cleaned often because she had a behavior of playing in her feces. CNA 1 stated in order to keep Resident 3 from reaching inside her incontinence brief, she would wrap the resident with a blanket FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 13 of 26 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 02/27/2020 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 from under their arms down to her knees. CNA 1 stated she also tied Resident 3's hospital gown into a knot and placed the knot underneath the resident's legs to keep her from reaching into her incontinence brief. CNA 1 stated she knew it was wrong, but she did not know how else to keep the resident clean. CNA 1 stated she was asked by the Administrator on 2/15/2020, if she had knowledge regarding Resident 3 being tied up. CNA 1 stated she told the Administrator she was responsible for Resident 3's clothing being tied tightly to restrict the resident's access to their feces. On 2/20/2020 at 0729 hours, a telephone interview was conducted with the Administrator. The Administrator stated he received a call on 2/15/2020, and was informed of Resident 3 was found with a her gown tied in a knot and secured underneath her legs. The Administrator stated he did not report or investigate the circumstances regarding this because he did not think it constituted abuse or a restraint. The Administrator stated Resident 3's gown was wrinkled and she was able to bend her knees, therefore Resident 3's movement was not restricted. The Administrator stated he interviewed CNA 1 and CNA 1 denied knotting Resident 3's gown. The Administrator verified nobody was suspended or corrective actions taken because there was no investigation. Review of the facility's assignment sheets for 2/15, 2/16, 2/17, and 2/18/2020, showed CNA 1 continued to be assigned to Resident 3 on the night shift (2300 to 0700 hours) for three days after Resident 3 was found with her gown knotted and wrapped tightly to purposely restrict the resident's movement and access to her body. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 14 of 26 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 02/27/2020 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

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

F607 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview, facility document review, and facility P&P review, the facility failed to implement their abuse P&P for screening of the prospective employees when they did not conduct the background checks for two CNAs. This failure had the potential to put the residents at risk for abuse, neglect, exploitation, or misappropriation of resident property. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 11/28/17, showed prior to hire, the facility will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 15 of 26 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 02/27/2020 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 screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit such abuse, neglect, exploitation, or misappropriation of resident property. This screening will include but not limited to: - Attempting to obtain information from previous employers and/or current employers, whether favorable or unfavorable. - Documentation of status and any disciplinary actions from licensing or registration boards and other registries. - Reviewing the prospective employee's employment history, especially when there is or may be a pattern of inconsistency. On 2/20/2020 at 1531 hours, an interview and concurrent facility document review was conducted with the Human Resources Manager. The Human Resources Manager was asked to show the evidenced background checks were conducted prior to hire for CNAs 9 and 24. The Human Resources Manager was unable to find any documented evidence the background checks were conducted prior to hire for CNAs 9 and 24. The Human Resources Manager stated CNAs 9 and 24 were part of the corporate acquisition which took place in May 2019. The Human Resources Manager stated all employees that were part of the acquisition should have had their background checks conducted as part of their continued employment with the new corporation.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 16 of 26 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 02/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS POST ACUTE 1800 Old Tustin Ave Santa Ana, CA 92705 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and facility P&P review, the facility failed to report potential abuse for one of three sampled residents (Resident 3) when Resident 3 was found with her gown tied tightly in a knot around her legs. This failure led to the delayed immediate protection of Resident 3 and delayed investigation of the alleged abuse. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 11/28/17, showed all allegations of abuse will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 17 of 26 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 02/27/2020 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 be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframe. Medical record review for Resident 3 was initiated on 2/19/2020. Resident 3 was readmitted to the facility on 3/12/11. Review of Resident 3's MDS dated 10/29/19, showed Resident 3 had moderately impaired cognition, required extensive one person assist for bed mobility, and had a limitation in ROM functions on both lower extremities. Review of Resident 3's History and Physical Examination dated 2/3/2020, showed Resident 3 did not have the capacity to understand and make decisions. On 2/19/2020 at 1314 hours, an interview was conducted with CNA 3. CNA 3 stated she found Resident 3 with the ends of her gown tightly tied together around her legs on 2/15/2020 around 0900 hours. CNA 3 stated the gown was tied so tightly that the resident could not move her legs. CNA 3 stated she immediately informed LVN 2. On 2/19/2020 at 1504 hours, a telephone interview was conducted with LVN 2. LVN 2 stated CNA 3 informed him she found Resident 3 with her gown tied in a knot on 2/15/2020. LVN 2 stated he went to Resident 3's room and found her with her gown double knotted. LVN 2 stated he informed the Administrator of what he found the same day. LVN 2 stated when he reported the incident to the Administrator he was advised it was not abuse. LVN 2 stated he did not initiate an incident report because when he spoke with the Administrator, the Administrator stated he did not consider it of any concern. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 18 of 26 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 02/27/2020 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 2/20/2020 at 0729 hours, a telephone interview was conducted with the Administrator. The Administrator stated he was notified on 2/15/2020, Resident 3 was found with her gown tied in a knot underneath her legs. The Administrator stated he did not investigate the circumstances regarding the knot in Resident 3's gown because he did not think it constituted an abuse or restraint. The Administrator stated Resident 3's gown was wrinkled and she was able to bend her knees; therefore, Resident 3's movement was not restricted. Cross reference to F600, example #2.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 19 of 26 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 02/27/2020 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: 2. Review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form dated 2/15/2020, showed the facility had reported an allegation of physical abuse for Resident 1. Resident 1 was found with the bed sheets tightly wrapped around his body restricting movement of his arms. Review of Resident 1's eInteract Change in Condition Evaluation dated 2/15/2020, showed Resident 1 was found with his upper and lower extremities wrapped with a bed sheet. The document showed Resident 1 did not sustain any injuries from the incident. Review of Resident 1's Census List dated 2/20/2020, showed Resident 1 was moved from Room A to Room B on 2/15/2020 at 1954 hours. Review of Resident 1's Allegation of AbuseInvestigation Report dated 2/20/2020, showed the staff interviews were conducted with LVN 7, CNA 1, LVN 2, and CNA 36. However, the investigation failed to show the documented interviews were conducted with the staff members who had witnessed and interviewed Resident 1 regarding the abuse allegation. The investigation also failed to show documented evidence other residents were questioned about possible abuse occurring in the facility. On 2/21/2020 at 1053 hours, a telephone interview was conducted with the ADON. The ADON was asked what her role was in the investigation of the abuse allegation for Resident 1. The ADON stated she conducted the staff and resident interviews and monitored Resident 1 for safety. The ADON was asked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 20 of 26 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 02/27/2020 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 whom she had conducted interviews with. The ADON stated she interviewed CNA 36, LVN 7, and a few of residents including Resident 1. The ADON was asked what type of questions she had asked Resident 1. The ADON stated she had asked how Resident 1 was doing, if he was experiencing any pain, and if he ate breakfast. The ADON stated she did not ask Resident 1 specific questions regarding the incident. The ADON verified she had interviewed six additional alert residents the same day. The ADON stated she had asked the residents how they were feeling and if they slept well the night before. The ADON verified she did not ask specific questions regarding the alleged abuse but instead asked general questions. The ADON was asked about the facility's investigation for Resident 1. The ADON stated the facility could not initially conclude who the alleged perpetrator was. The ADON stated anyone from any shift could be the perpetrator. The ADON added it could be a nurse or a CNA. The ADON was asked if any changes to the staffing or assignment was done in the effort to protect Resident 1. The ADON stated the facility did not. The ADON was asked if anyone was removed from Resident 1's care. The ADON stated no. The ADON verified CNA 22 worked on 2/15, 2/16, 2/17, 2/18 and 2/19 following the day Resident 1 was discovered wrapped in a blanket. The ADON was asked if CNA 22 had access to all the residents in the facility. The ADON stated CNA 22 did. On 2/21/2020 at 1125 hours, a telephone interview was conducted with the Administrator. The Administrator was asked what his role was when there was an allegation of abuse. The Administrator stated he was the facility's Abuse Coordinator and his role included investigating all abuse allegations; reporting the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 21 of 26 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 02/27/2020 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 allegations of abuse to the state agency, LongTerm Ombudsman, and police; and complete the 5-day investigation. The Administrator added he also conducted the interviews. The Administrator was asked about the events that took place on 2/15/2020. The Administrator stated RN 1 informed him of two residents (Residents 1 and 3) found with the end of the gowns tied around the residents' legs and one resident (Resident 1) was found tightly wrapped with the blanket. The Administrator stated RN 1 had informed him Resident 1 stated a female CNA had wrapped Resident 1 with a blanket. The Administrator stated he did have an idea who the suspected abuser was the same day the abuse allegation was reported. The Administrator was asked if he had removed the suspected abuser from the care of Resident 1. The Administrator stated he did not and explained when he interviewed CNA 22, she denied tightly wrapping Resident 1 with a blanket. The Administrator stated he could not make a conclusion of the investigation at that point. The Administrator verified the Investigation Report included all the interviews conducted during the investigation. The Administrator was asked if he interviewed CNA 4 who witnessed Resident 1 wrapped tightly in a blanket and his gown tied up in a knot. The Administrator stated he did not, but should have. The Administrator was asked if he interviewed RN 1 regarding her conversation with Resident 1. The Administrator stated he did not. Cross reference to F600, example #1. 3. Review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form dated 2/13/2020, showed the facility had reported an allegation of sexual abuse for Resident 2. Resident 2 alleged he was awaken with CNA 22's hands under his incontinence FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 22 of 26 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 02/27/2020 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 briefs around the pubic area. Review of Resident 2's Allegation of AbuseInvestigation Report dated 2/18/2020, showed the facility could not substantiate the allegation. The investigation showed interviews were conducted with CNA 22 and LVN 1. However, the investigation failed to show documentation other staff members were interviewed. On 2/21/2020 at 1146 hours, an interview was conducted with the Administrator. The Administrator verified all interviews conducted were in the final investigation report. The Administrator stated he only interviewed LVN 1 and CNA 22 and no other staff members who could be possible witnesses to the alleged incident. Based on observation, interview, medical record review, and facility P&P review, the facility failed to thoroughly investigate allegations of abuse for three of three sampled residents (Residents 1, 2, and 3). * The facility failed to investigate allegations of abuse when Resident 3 was found with her gown tied tightly around her legs, restricting her movement. * The facility failed to thoroughly investigate allegations of abuse when Resident 1 was found tightly wrapped in a blanket and his gown tied tightly around his legs, restricting his movement. * The facility failed to thoroughly investigate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 23 of 26 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 02/27/2020 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 allegations of abuse when Resident 2 was awaken with CNA 22's hand inside his incontinence briefs. These failures put the residents at risk for further abuse and resulted in Resident 3 being subjected to further abuse when she was found with her gown tucked tightly underneath her, preventing access to her body. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 11/28/17, showed if an allegation of abuse is reported, discovered, or suspected, the facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation: - Respond immediately to protect the alleged victim and integrity of the investigation. - Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. All allegations of abuse will be promptly and thoroughly investigated by the Administrator and/or his designee. The investigation will include the following: - An interview with staff members (on all shifts) who may have information regarding the alleged incident. - Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident. - An interview with staff members (on all shifts) having contact with the accused employee; and - A review of all the circumstances surrounding the incident. If the allegation of abuse involves an employee, the facility will immediately suspend the employee from the care of any resident, and suspend the employee during the investigation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 24 of 26 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 02/27/2020 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 pending. 1. Medical record review for Resident 3 was initiated on 2/19/2020. Resident 3 was readmitted to the facility on 3/12/11. Review of Resident 3's MDS dated 10/29/19, showed Resident 3 had moderately impaired cognition, required extensive one person assist for bed mobility, and had limitation in ROM functions on both lower extremities. Review of Resident 3's History and Physical Examination dated 2/3/2020, showed Resident 3 did not have the capacity to understand and make decisions. On 2/19/2020 at 1314 hours, an interview was conducted with CNA 3. CNA 3 stated she found Resident 3 with the ends of her gown tightly tied together around her legs on 2/15/2020 around 0900 hours. CNA 3 stated the gown was tied so tightly the Resident 3 could not move her legs. CNA 3 stated she immediately informed LVN 2. On 2/19/2020 at 1504 hours, a telephone interview was conducted with LVN 2. LVN 2 stated CNA 3 informed him she found Resident 3 with her gown tied in a knot on 2/15/2020. LVN 2 stated he went to Resident 3's room and found her with her gown double knotted. LVN 2 stated he did a body assessment and then informed the Administrator. LVN 2 stated when he reported the incident to the Administrator the same day, he was advised it was not abuse. LVN 2 stated he did not document the assessment, do a Change of Condition report, nor generate an incident report because when he spoke with the Administrator, the Administrator stated he did not consider it was of any concern. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 25 of 26 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 02/27/2020 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 2/20/2020 at 0729 hours, a telephone interview was conducted with the Administrator. The Administrator stated he was notified on 2/15/2020, Resident 3 was found her gown tied in a knot underneath her legs. When asked if he investigated the alleged abuse, The Administrator stated he asked CNA 1 if she was responsible for knotting Resident 3's gown and she denied the allegation. The Administrator stated he did not initiate an investigation because he did not think the incident constituted an abuse or restraint. The Administrator stated Resident 3's gown was wrinkled and she was able to bend her knees; therefore, Resident 3's movement was not restricted. Cross reference to F600, example #2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AUOR11 Facility ID: CA060000094 If continuation sheet 26 of 26