Health inspection·November 2, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning; thinking, remembering, and reasoning; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/5/2023 indicated Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's physician orders dated 9/8/2023 indicated the following orders: a. Apply soft belt while up on the wheelchair, every day and evening shift. b. Assess skin integrity: release soft belt every two hours, every day and evening shift. During a review of Resident 38's Risk for Fall Care Plan initiated 9/8/2023, indicated to apply the soft belt for trunk (body) control and to let Resident 38's wife sign the informed consent. During a concurrent observation and interview on 10/31/2023 at 8:56 a.m., observed Resident 38 sitting in a wheelchair in the activities room with a soft belt restraint applied around the resident's waist and secured to the back of the wheelchair frame. Resident 38 did not respond to questions. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with Registered Nurse 1 (RN 1), Resident 38's Verification of Informed Consent for Chemical Restraints (a form of medical restraint in which a drug is used to restrict the freedom or movement of a resident) or Physical Restraints Form dated 9/8/2023 was reviewed. RN 1 stated the process for applying a restraint is to obtain a physician's order for the use of restraint, obtain a signed informed consent from the resident's responsible party, complete a restraint assessment form, and monitor the safety and use of the restraint. RN 1 stated Resident 38's Verification of Informed Consent for Chemical Restraints/Physical Restraints Form dated 9/8/2023 was not complete because it did not have a physician signature and it did not have Resident 38's responsible party's signature. RN 1 stated she called Resident 38's physician on 9/8/2023 to obtain the informed consent for the use of the soft belt restraint, but the physician did not complete or sign the informed consent form for Resident 38. RN 1 stated the importance of getting a signed consent is to have documented evidence that the physician informed the resident's responsible party of the reason for the restraint, the probable duration, the risks, and the right to accept or refuse the restraint. During a concurrent interview and record review on 10/31/2023 at 4:08 p.m. with the Director of Nursing (DON), the DON reviewed Resident 38's Verification of Informed Consent for Chemical Restraints/Physical Restraints form dated 9/8/2023. The DON stated the facility policy is that an informed consent for restraint must be signed by the physician and the resident's responsible party. The DON stated that since Resident 38's Verification of Informed Consent for Chemical Restraints/Physical Restraints form dated 9/8/2023 was not signed by Resident 38's physician or responsible party, the form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 2 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 was not completed and the facility policy of obtaining an informed consent was not followed. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated restraints shall only be used for the safety and wellbeing of residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Residents Affected - Few 2. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with RN 1, Resident 38's medical records were reviewed to find documented evidence that a Pre-Restraint Assessment Form was completed from 9/8/2023 to 10/31/2023, no documented evidence was found. RN 1 stated the facility uses a restraint assessment form to document the need for the restraint and assessment for the safety of use. RN 1 stated there was no documented evidence a restraint assessment was completed prior to administering the soft belt to Resident 38 starting on 9/8/2023. During a concurrent interview and record review on 10/31/2023 at 4:08 p.m. with the DON, Resident 38's medical records were reviewed to find documented evidence that a Pre-Restraint Assessment Form was completed from 9/8/2023 to 10/31/2023, no documented evidence was found. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated that prior to placing the resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 3. A review of Resident 38's physician orders dated 9/8/2023 indicated the following orders: a. Apply soft belt while up on the wheelchair, every day and evening shift. b. Assess skin integrity: release soft belt every two hours, every day and evening shift. During a concurrent interview and record review on 10/31/2023 at 4:08 p.m. with the DON, the DON reviewed Resident 38's physician order for a soft belt restraint dated 9/8/2023. The DON stated that Resident 38's physician order for the soft belt restraint was not complete because the facility policy indicates that restraint orders must include the specific reason for the restraint, the period of time for the use of the restraint, and how the restraint would benefit the resident's medical symptom. The DON stated the Resident 38's physician order for soft belt restraint only indicated to apply the soft belt restraint and did not include the reason, benefit to the resident, and duration of use. The DON stated the order should have included that it was used for poor trunk control to prevent toppling from the wheelchair, to prevent injury, and the duration of use. The DON stated the importance of following the facility policy for the use of restraints is to ensure applied restraints are used appropriately and to prevent any negative outcome like injury. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated restraints shall only be used for the safety and wellbeing of residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used upon the written order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 3 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 of a physician and after obtaining consent from the resident and/or representative. The order shall include: Level of Harm - Minimal harm or potential for actual harm a. the specific reason for the restraint (as it relates to the resident's medical symptom). Residents Affected - Few b. how the restraint will be used to benefit the resident's medical symptom, c. the type of restraint, and period of time for the use of the restraint. 4. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with RN 1, Resident 38's medical records from 9/8/2023 to 10/31/2023 were reviewed to find documented evidence that Resident 38 was monitored every 30 minutes while the resident was restrained by the soft belt restraint. The review of Resident 38's medical records included progress notes, restraint assessment forms, Medication Administration Record (MAR- used to document medications taken by a resident), Treatment Administration Record (TAR- used to document the various healthcare treatment provided to a resident) and Restraint assessment forms. RN 1 stated that according to Resident 38's MAR for 10/2023, Resident 38 was restrained daily with the use of a soft belt restraint. RN 1 stated that there was no documented evidence found from 9/8/2023 to 10/31/2023 to indicate that facility staff monitored Resident 38 every 30 minutes anytime the resident was restrained with a soft belt restraint. RN 1 stated the facility's restraint policy indicates that facility staff is to document monitoring of a restrained resident every 30 minutes. RN 1 stated due to the safety risk posed by the restraint, Resident 38 should be monitored every 30 minutes while restrained for resident safety. RN 1 stated there was no documented evidence the resident was monitored for safety while the restraint was in use. A review of the facility policy and procedure titled, Use of Restraints, last reviewed 10/11/2023, indicated the following safety guidelines shall be implemented and documented while a resident is in restraints: a resident in restraints will be observed at least every thirty minutes by nursing personal and an account of the resident's condition shall be recorded in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 4 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of 17 sampled residents (Resident 9 and Resident 38) by failing to: 1. Ensure a care plan for oxygen therapy (a treatment that provides extra oxygen to help people with lung diseases or breathing problems) was developed for Resident 9. 2. Ensure a care plan for Resident 9's pacemaker (a small electrical device that's implanted in the chest or abdomen to help your heartbeat at a normal rate and rhythm) was developed. 3. Ensure a care plan for the use of a soft belt restraint (a foam-padded pelvic restraint with ties secured around the back of wheelchair designed to help prevent forward sliding in wheelchairs) was developed for Resident 38. These deficient practices had the potential to result in a delay in or lack of delivery of care and services. Findings: 1. A review of Resident 9's admission Record indicated the facility originally admitted the resident on 4/7/2023 and readmitted the resident on 7/14/2023 with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated the resident had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experiences, and the senses) skills for daily decision making and was totally dependent on staff for locomotion (movement or the ability to move from one place to another) on and off the unit and toilet use. On 10/30/2023 at 10:20 a.m., during a concurrent observation and interview, observed Resident 9 asleep in bed receiving oxygen via nasal cannula (a device that delivers extra oxygen through a tube and into your nose). Licensed Vocational Nurse 1 (LVN 1) stated that Resident 9 was receiving oxygen at four [4] liters per minute (LPM - flow rate of oxygen; unit of measure). On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review with the Director of Staff Development (DSD), Resident 9's care plans from 7/14/2023 to 11/1/2023 were reviewed. The DSD stated that Resident 9 had no care plans addressing the resident's use of oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 5 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that a resident receiving oxygen therapy should have a care plan in place so that staff is aware of what needs to be monitored, or so that staff knows what to look for in the event the resident has a change in condition (a sudden and clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains). RN 1 stated if there was no care plan for staff to follow, Resident 9 could potentially experience complications such as shortness of breath or oxygen toxicity (lung damage that occurs when someone breathes in too much extra oxygen). 2. A review of Resident 9's physician's orders dated 9/3/2023, indicated the following orders: a. Pacemaker monitoring: Avoid activities and equipment which interfere with pacemaker activity: large magnets, magnetic resonance imaging (MRI - a painless medical imaging procedure that uses radio waves and a magnetic field to create detailed images of the inside of the body) scanner, electric razor, microwave, diathermy (a therapeutic treatment that uses electric currents to generate heat in layers of your skin below the surface), transcutaneous electrical nerve stimulator (TENS - a small, battery-operated device that sends electrical pulses through the skin to relieve pain) machine, and radio frequency ablation (a minimally invasive technique that uses radio waves to create heat and destroy tissue) every shift. b. Pacemaker monitoring: Monitor and report to the medical doctor (MD) heart rate less than 60 or greater than 100 beats per minute (BPM) due to pacemaker in place. Monitor every shift. c. Pacemaker monitoring: Observe pacemaker site for infection such as pain, redness, swelling, drainage, warmth, and discoloration (change in your skin that differs from your natural skin tone). Notify MD and monitor every shift. On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review with the DSD, Resident 9's care plans from 7/14/2023 to 11/1/2023 were reviewed. The DSD stated that Resident 9 had no care plan addressing the presence of his pacemaker. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated it was important to have a care plan for Resident 9's pacemaker so that staff is aware of what needed to be monitored, or so that staff knew what to do in case there were any complications related to Resident 9's pacemaker. 3. A review of Resident 38's admission Record indicated the facility admitted the resident on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 6 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A review of Resident 38's MDS dated [DATE], indicated Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. Level of Harm - Minimal harm or potential for actual harm A review of Resident 38's physician orders dated 9/8/2023, indicated the following orders: Residents Affected - Few a. Apply soft belt while up on the wheelchair, every day and evening shift. b. Assess skin integrity: release soft belt every two hours, every day and evening shift. During a concurrent interview, and record review on 10/31/2023 at 9:20 a.m. with RN 1, Resident 38's care plans from 9/8/2023 to 10/31/2023 were reviewed. RN 1 stated there was no documented evidence that a soft belt restraint care plan was developed for Resident 38. RN 1 stated the importance of a restraint care plan is to guide the residents care and communicate the resident's issues and specific interventions to the healthcare team. RN 1 stated that without a care plan, there is nothing to guide the resident's care. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 10/11/2023, indicated it was the facility's policy that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals, timetables and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aid in preventing or reducing decline in the resident's functional status and/or functional levels; and reflect currently recognized standards of practice for problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 7 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to: 1. Ensure that a resident who was at high risk for falls had their bed in a low position for one (Resident 44) of five sampled residents investigated for accidents. 2. Ensure the information for a resident's pacemaker (a small electrical device that's implanted in the chest or abdomen to help your heartbeat at a normal rate and rhythm) was readily available in the resident's medical record for one (Resident 9) of five sampled residents investigated for accidents. 3. Ensure that a licensed nurse did not leave a resident's blood pressure medication at the bedside for one (Resident 13) of five sampled residents investigated for accidents. 4. Ensure one of five sampled residents (Resident 56) investigated for Accidents did not have an opened bottle of 0.9 percent (%-unit of measure) Sodium Chloride Irrigation solution (Normal Saline [NS], a sterile solution composed of sodium chloride [salt] in water used for cleansing wounds) left unlabeled and on the resident's nightstand. 5. Ensure licensed nurse did not leave a resident's amlodipine (medication to treat high blood pressure) and hydrochlorothiazide (medication to treat high blood pressure) for one of six sampled residents (Resident 46) observed for Medication Administration in the resident's room unattended. These deficient practices had the potential to place Resident 44 at increased risk of sustaining a fall with injuries, place Resident 9 at increased risk of suffering complications in the event of a pacemaker malfunction, and Resident 13 at risk of experiencing adverse effects from not receiving his blood pressure medications; placed Resident 56 at increased risk of ingesting substances not intended for them resulting in adverse effects such as an upset stomach; and placed Resident 46 at increased risk for hypotension (low blood pressure) and dizziness or headaches for taking medications not intended for them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 8 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Some A review of Resident 44's admission Record indicated the facility originally admitted Resident 44 on 12/9/2019 and readmitted Resident 44 on 6/24/2022 with diagnoses including multiple sclerosis (a disorder that affects the brain, spinal cord, and optic nerves), muscle wasting and atrophy (when muscles waste away and look smaller than normal), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), epilepsy (a chronic, noncommunicable brain disorder that causes recurrent, unprovoked seizures), and age-related osteoporosis (a chronic bone disease that occurs when bone mineral density and bone mass decrease, or when the quality or structure of bone changes). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/12/2023, indicated Resident 44 had severe impairment in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for locomotion (movement or the ability to move from one place to another) off the unit and toilet use. A review of Resident 44's Fall Risk Assessment (tool used to check how likely it is a resident will fall) dated 8/12/2023 indicated that Resident 44 is identified as a high risk for fall. A review of Resident 44's care plan titled Risk for Fall Injury dated 6/27/2022 indicated Resident 44 is at high risk for fall and injury related to cognitive impairment, poor safety awareness, weakness, visual impairment, and medical diagnoses. The goal was to minimize risk for falls, minimize injury and minimize recurrence of falls. The interventions included are to implement fall precautions, provide a safe environment and to provide adequate assistance and frequent safety reminder. On 10/30/2023 at 10:36 a.m., during an observation, observed Resident 44 awake in bed watching television; Resident 44's bed was noted in the high position (the mattress of the bed high and further distance from the floor). On 10/30/2023 at 10:41 a.m., during a concurrent observation and interview, Registered Nurse 1 (RN 1) Resident 44's bed position was observed. RN 1 stated that Resident 44's bed was in the high position. RN 1 stated that Resident 44 was identified as a high risk for falls, and the resident's bed should be kept in a low position (the mattress is closer to the floor to prevent injuries in the event of a fall). On 11/1/2023 at 9:42 a.m., during a concurrent interview and record review, reviewed Resident 44's Fall Risk Assessment (tool used to check how likely it is a patient will fall), dated 8/12/2023, with RN 1. RN 1 stated that the resident's score of 13 indicated she was at high risk for falls. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that if the bed is kept in a high position for a resident who is at high risk for falls, the resident can potentially fall off the bed and sustain major injuries such as fractured (broken) bones or head trauma (head injury). A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, last reviewed on 10/11/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Environmental factors that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 9 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm contribute to the risk of falls include .incorrect bed height or width. Resident conditions that may contribute to the risk of falls include delirium and other cognitive impairment, lower extremity weakness, and functional impairments. 2. Residents Affected - Some A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 4/7/2023 and readmitted Resident 9 on 7/14/2023 with diagnoses including pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's MDS dated [DATE], indicated Resident 9 had severely impaired cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit and toilet use. A review of Resident 9's Physician's Orders dated 9/3/2023 indicated the following orders: Pacemaker monitoring: Avoid activities and equipment which interfere with pacemaker activity: large magnets, magnetic resonance imaging (MRI - a painless medical imaging procedure that uses radio waves and a magnetic field to create d detailed images of the inside of the body) scanner, electric razor, microwave, diathermy (a therapeutic treatment that uses electric currents to generate heat in layers of your skin below the surface), transcutaneous electrical nerve stimulator (TENS - a small, battery-operated device that sends electrical pulses through the skin to relieve pain) machine, and radio frequency ablation (a minimally invasive technique that uses radio waves to create heat and destroy tissue) every shift. Pacemaker monitoring: Monitor and report to the physician heart rate less than 60 or greater than 100 beats per minute (BPM) due to pacemaker in place. Monitor every shift. Pacemaker monitoring: Observe pacemaker site for infection such as pain, redness, swelling, drainage, warmth, and discoloration. Notify the physician and monitor every shift. On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review with the Director of Staff Development (DSD), Resident 9's medical records that included progress notes, physician orders, care plans, and consultations from 4/7/2023 to 11/1/2023 were reviewed. DSD stated that she could not find any information regarding Resident 9's pacemaker in the resident's medical records. The DSD stated a residents pacemaker information should be readily available in the resident's medical record. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that, for a resident with a pacemaker, there should be information in the resident's medical record about the cardiologist, the model, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 10 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some serial number, and date of when the pacemaker was implanted. RN 1 stated that information should be readily available in the resident's medical record in case the resident's pacemaker malfunctioned. RN 1 stated if the facility did not have Resident 9's pacemaker information readily available. RN 1 stated that the facility would not be able to communicate information related to Resident 9's pacemaker to the emergency medical technician (EMT - a medical professional who provides emergency care to people outside of or on the way to the hospital) or general acute care hospital (GACH) if Resident 9 needed to be transferred out. A review of the facility's policy and procedure titled, Pacemaker, Care of a Resident with, last reviewed on 10/11/2023, indicated that for each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address, and telephone number of the cardiologist b. Type of pacemaker c. Type of leads (thin, insulated wires that transmit electrical impulses from the pacemaker to the heart muscle to assist blood flow) d. Manufacturer and model e. Serial number f. Date of implant; and g. Paced rate 3. A review of Resident 13's admission Record indicated the facility admitted Resident 13 on 1/3/2020 with diagnoses including hypertension (a condition in which the pressure in your blood vessels is too high). A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had intact cognition and required supervision with bed mobility, transfers, locomotion on and off the unit, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 11 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 13's Physician's Order, dated 8/3/2021, indicated to give Atenolol (a medication used to mainly treat angina [condition marked by severe pain in the chest] and high blood pressure) 25 milligrams (mg- unit of measure) one tablet by mouth two times a day for hypertension. Hold for systolic blood pressure (SBP - indicates how much pressure your blood is exerting against your artery walls when the heart beats) less than 110 millimeters of mercury (mmHg-unit of measure) or pulse rate less than 60 beats per minute (BPM). A review of Resident 13's Medication Self-Administration Assessment Form, dated 10/11/2023, indicated Resident 13 cannot safely self-administer medications. On 10/31/2023 at 9:03 a.m., during a medication administration observation, observed Licensed Vocational Nurse 2 (LVN 2) hand Resident 13's Atenolol medication to the resident in a medication cup and proceeded to close the resident's privacy curtain before walking back to the medication cart. Observed LVN 2 fail to monitor Resident 13 to ensure the resident took the medication. On 10/31/2023 at 9:27 a.m., during an interview, LVN 2 stated that she did not observe Resident 13 take his Atenolol medication before walking away from the resident. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that licensed nurses should not be leaving residents alone with their medication. RN 1 stated licensed nurses should observe residents to ensure they actually take their medication. RN 1 stated if licensed nurses does not observe the resident take the provided medication, it is possible that the resident may not take the medication resulting in adverse health effects such as high blood pressure. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that medications are administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the facility's policy and procedure titled, Administering Oral Medications, last reviewed on 10/11/2023, indicated that the purpose of the procedure is to provide guidelines for the safe administration of oral medications. Remain with the resident until all medications have been taken. 4. A review of Resident 56's admission Record indicated the facility admitted Resident 56 on 2/2/2023 and readmitted Resident 56 on 10/13/2023 with diagnoses that included heart disease (a group of disorders that affect the heart's ability to deliver oxygen to the body), Alzheimer's disease (a type of dementia [a group of symptoms that affects memory, thinking, and behavior]), and contractures of muscle (shortening of length of muscle). A review of Resident 56's MDS dated [DATE], indicated Resident 56 rarely/never had the ability to understand others and rarely/never had the ability to make herself understood. During an observation on 10/30/2023 at 10:42 a.m., observed Resident 56 lying in bed awake; Resident 56 did not respond to questions. Observed an opened bottle of unlabeled NS irrigation solution on Resident 56's nightstand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 12 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 10/30/2023 at 10:48 a.m. with Certified Nursing Assistant 1 (CNA 1), the opened bottled of unlabeled NS irrigation solution on Resident 56's nightstand was observed. CNA 1 stated she cares for Resident 56 often and uses the NS daily with a piece of gauze (thin translucent fabric) given to her by Treatment Nurse 1 (TN 1) to clean the resident's contracted left hand. CNA 1 stated she opened the bottle of NS last week and left it on Resident 56's nightstand. Residents Affected - Some During an interview on 11/1/2023 at 9:12 a.m. with TN 1, TN 1 stated he did not leave a bottle of NS on Resident 56's nightstand. TN 1 stated NS is stocked in the clean utility room that Certified Nursing Assistants (CNAs) have access to. TN 1 stated NS is only used for cleansing wounds and not for cleaning a resident's hand. TN 1 stated water and soap is used to clean hands, not NS. TN 1 stated NS should not be applied by CNAs to a resident and should never be left in a resident's room because it looks like water and any resident could ingest it. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated the bottle of NS should not have been left on Resident 56's nightstand. RN 1 stated that if NS is ingested by a resident, it could lead to a stomach upset. A review of the facility policy and procedure titled, Hazardous Areas, Devices, and Equipment, last reviewed 10/11/2023 indicated all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate hazards to the extent possible. A hazard is identified as anything in the environment that has the potential to cause injury or illness. During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 10/11/2023 indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 5. A review of Resident 46's admission Record indicated the facility admitted Resident 46 on 8/12/2021 and readmitted Resident 46 on 3/21/2022 with diagnoses that included parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors), hypertension, and schizoaffective disorder (a mental health disorder with symptoms of hallucinations [a false perception of objects or events involving your senses] or delusions [false belief or judgment about external reality]). A review of Resident 46's MDS dated [DATE], indicated Resident 46 usually had the ability to understand others and usually had the ability to make himself understood. A review of Resident 46's Physician Orders indicated the following orders: a. Amlodipine Besylate tablet 10 mg, give one tablet by mouth one time a day related to essential hypertension, dated 3/22/2022. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 13 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hydrochlorothiazide tablet 25 mg, give one tablet by mouths one time a day for hypertension, dated 3/21/2022. During a concurrent observation and interview on 11/1/2023 at 8:08 a.m. with Licensed Vocational Nurse 3 (LVN 3), observed LVN 3 take Resident 46's blood pressure then walked back to the medication cart in the hallway. Resident 46 motioned to the surveyor and stated he had something. Observe Resident 46 open a tissue and observed two pills inside the tissue. LVN 3 entered the room and asked Resident 46 where he got the medications from. Resident 46 stated he got the medications off the floor last night. LVN 3 identified the medications as Amlodipine and Hydrochlorothiazide. LVN 3 stated she did not know when or from whom Resident 46 got the medications. LVN 3 stated the medication nurse should always ensure the resident takes the provided medications before leaving the room. During a concurrent interview and record review on 11/1/2023 at 11:22 a.m. with the Infection Preventionist (IP), the IP reviewed Resident 46's Medication Self Administration Assessment Form, dated 9/29/2023 and stated the resident was assessed and it was determined Resident 46 could not safely self-administer medications due to the resident not being able to demonstrate reading medication instructions aloud, verbalize times at which medications are to be taken, verbalize understanding of the purpose of medications and potential side effects, demonstrate opening medication packages, or storing medications properly. The IP stated Resident 46 should not have medications left in his room. The IP stated it was unsafe for Resident 46 to have medications left in his room because those medications have parameters that need to be followed and if taken at the wrong time, he could overdose with the potential to cause an adverse side effect like low blood pressure. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated whoever gave the Amlodipine medication and Hydrochlorothiazide medication to Resident 46 did not follow the facility policy and procedure to ensure the medication was taken before leaving the resident's room; or the licensed nurse may have left the medications at Resident 46's bedside for the resident to self-administer. RN 1 stated leaving medications at Resident 46's bedside was a safety issue and placed the resident at risk for self-administering the medication at the wrong time resulting in his blood pressure dropping and causing dizziness with falls and injury. A review of the facility policy and procedure titled, Administering Medications, last reviewed 10/11/2023 indicated medications are administered in a safe and timely manner and as prescribed. A review of the facility procedure titled, Administering Oral Medications, last reviewed 10/11/2023 indicated the purpose of the procedure was to provide guidelines for the safe administration of oral medications. Remain with the resident until all medications have been taken. During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 10/11/2023 indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 14 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident receiving oxygen had a physician's order for oxygen therapy (a treatment that provides extra oxygen to help people with lung diseases or breathing problems) for one of one sampled resident (Resident 9) investigated for oxygen therapy. Residents Affected - Few This deficient practice had the potential to result in Resident 9 experiencing adverse effects due to inadequate or higher than necessary rates of oxygen administration leading to a negative impact to the resident's overall health. Findings: A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 4/7/2023 and readmitted Resident 9 on 7/14/2023 with diagnoses that included pneumonia (an infection that inflames the air sacs in one or both lungs) and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within seven days). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated Resident 9 had severely impaired cognitive (the mental action or process of acquiring knowledge and understanding through thought, experiences, and the senses) skills for daily decision making and was totally dependent on staff for locomotion (movement or the ability to move from one place to another) on and off the unit and toilet use. On 10/30/2023 at 10:20 a.m., during a concurrent observation and interview, observed Resident 9 asleep in bed receiving oxygen via nasal cannula (a device that delivers extra oxygen through a tube and into your nose). Licensed Vocational Nurse 1 (LVN 1) stated that Resident 9 was receiving oxygen at four [4] liters per minute (LPM - flow rate of oxygen; unit of measure). On 11/1/2023 at 8:17 a.m., during a concurrent interview and record review, reviewed Resident 9's physician's orders from 7/14/2023 to 11/1/2023 with the Director of Staff Development (DSD). The DSD stated there was no physician's order for Resident 9 to receive oxygen therapy. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated there should have been a physician's order if a resident is receiving oxygen therapy. RN 1 stated it was important to have an order for oxygen therapy so that staff knew how many liters per minute the resident should be receiving. RN 1 stated that if the resident was receiving oxygen without a physician's order, it is possible for the resident to suffer complications such as shortness of breath or oxygen toxicity (lung damage that occurs when someone breathes in too much extra oxygen) if licensed nurses did not have a specific order to follow. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/11/2023, indicated that the purpose of this procedure is to provide guidelines for safe oxygen administration. The policy further indicated to verify that there is a physician's order for oxygen therapy, and to review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 15 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to: Residents Affected - Some 1. Ensure licensed nurses followed up with the pharmacy when a resident's Isosorbide (a medication used to prevent angina [chest pain] in residents with a certain heart condition) medication had not been delivered for one (Resident 112) out of six sampled residents observed during medication administration. 2. Ensure licensed nurse staff documented either at the start of the shift, or the end of the shift on Medication Cart 2 Floor Narcotic (a type of medication that is used to relieve pain but has a high potential for abuse) Release form (a form that is signed by both the oncoming shift licensed nurse and the outgoing shift licensed nurse after they have both verified by counting that all controlled medications [medications that can cause physical and mental dependence such as narcotics]) for 12 of 127 shifts. 3. Ensure licensed nurses documented the administration of Ativan (a medication used to treat anxiety [a persistent feeling of worry, nervousness, or unease]) for one of five sampled resident's (Resident 38) for 15 of 16 occurrence in the residents Medication Administration record (MAR- a report detailing the drugs administered to a resident by a healthcare professional) for 10/2023 These deficient practices had the potential to place the residents at increased risk of experiencing adverse health effects form not receiving their due prescribed medications; had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications; and had the potential to result in confusion in the care and services provided to the residents. Findings: 1. A review of Resident 112's admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including hypertension (HTN - high blood pressure) and atrial fibrillation (an irregular heartbeat and often very rapid heartbeat rhythm). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 16 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 112's Physician Orders indicated an order dated 10/19/2023 for Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Registered Nurse 1 (RN 1) call the facility's contracted pharmacy and spoke with Certified Pharmacy Technician 1 (CPhT 1). CPhT 1 stated that Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that if a resident's medication was not available, the licensed nurse should check the physician's order and follow up with the pharmacy so that the pharmacy can send the resident's needed medication. RN 1 stated Resident 112 could have possibly suffered from adverse effects such as a stroke (happens when there is a loss of blood flow to part of the brain) or uncontrolled blood pressure since the resident was not receiving his ordered blood pressure medication. A review of the facility's policy and procedure titled, Pharmacy Services Overview, last reviewed on 10/11/2023, indicated that the facility shall accurately and safely provide and obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist. 2. During a concurrent interview and record review on 11/1/2023 at 7:48 a.m. with Licensed Vocational Nurse 3 (LVN 3), Nursing Station 2 Medication Cart Floor Narcotic Release form for 9/2023 and 10/2023 were reviewed. LVN 3 stated that there were missing documentation entries on the Floor Narcotic Release form for Nursing Station 2 Medication Cart. LVN 3 stated the following missing entries: a) On 9/20/2023 at 7:00 a.m., missing the on-coming nurse's signature and if the narcotic count is short or over. b) On 9/21/2023 at 7:00 a.m., missing the on-coming nurse's signature and if the narcotic count is short or over. c) On 9/21/2023 at 3:00 p.m., missing the outgoing nurse's signature. d) On 10/1/2023 at 11:00 p.m., missing the outgoing nurse's signature. e) On 10/5/2023 at 11:00 p.m., missing the outgoing nurse's signature. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 17 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 f) Level of Harm - Minimal harm or potential for actual harm On 10/6/2023 at 11:00 p.m., missing the outgoing nurse's signature. g) Residents Affected - Some On 10/15/2023 at 3:00 p.m., missing the on-coming nurse's signature and if the narcotic count is short or over. h) On 10/15/2023 at 11:00 p.m., missing the outgoing nurse's signature. i) On 10/16/2023 at 3:00 p.m., missing the on-coming nurse's signature and if the narcotic count is short or over. j) On 10/16/2023 at 11:00 p.m., missing the outgoing nurse's signature. k) On 10/18/2023 at 7:00 a.m., missing the on-coming nurse's signature. l) On 10/18/2023 at 3:00 p.m., missing the outgoing nurse's signature. LVN 3 stated a narcotic count is completed each shift with the oncoming and outgoing nurse to document proof that all controlled medications are account for. LVN 3 stated that if the narcotic count is correct and validated by two nurses, it ensures that there are no missing narcotic medications prior to the start of the next nurse's shift. LVN 3 stated narcotics go missing and are stolen more often than other medications and it is important to account for them. LVN 3 stated if it was not documented as completed on the Floor Narcotic Release form, then it was not done. During an interview on 11/1/2023 at 11:18 a.m. with the Infection Preventionist (IP), the IP stated the Narcotic Count Release form is used to document the outgoing nurse's release of responsibility over the medication cart and narcotics to the oncoming nurse. The IP stated if there was a discrepancy then the oncoming nurse should refuse to accept the cart until the discrepancy is resolved. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated the importance of the Narcotic Release form is to ensure both nurse's count the controlled medications together. RN 1 stated that if a narcotic medication count is not completed, it could potentially lead to missing controlled medications and not being able to identify when they went missing or who was responsible for the missing controlled medications. RN 1 stated the facility policy was not followed because the oncoming and outgoing nurse must document the count of the controlled medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 18 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy titled, Controlled Substances last reviewed 10/11/2023, indicated only licensed nursing and pharmacy personnel shall have access to Schedule II controlled drugs (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) maintained on premises. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. 3. A review of Resident 38's admission Record indicated the facility admitted the resident on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/5/2023 indicated Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's Physician Orders indicated an order for Ativan tablet 0.5 mg, give one tablet by mouth every eight hours as needed for anxiety manifested by restlessness leading to exhaustion, dated 1/26/2023. During a concurrent interview and record review on 11/1/2023 at 9:45 a.m., with the IP, the IP reviewed Resident 38's Ativan 0.5 mg Medication Count Sheet (a record detailing the number of medication doses removed from a bubble pack [packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover]), and Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) for 10/2023; the IP noted the following: a. On 10/1/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. b. On 10/4/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. c. On 10/6/2023 at 10:00 a.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 19 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/6/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. e. On 10/7/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. f. On 10/8/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. g. On 10/12/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. h. On 10/13/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. i. On 10/18/2023 at 5:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. j. On 10/19/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. k. On 10/20/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. l. On 10/24/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. m. On 10/29/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. n. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 20 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/30/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. o. On 10/31/2023 at 9:00 p.m., Ativan 0.5 mg was removed from the count sheet and not documented as administered in the MAR. The IP stated the medication nurse must document administration of Ativan in Resident 38's MAR on the date and time of administration. During a concurrent interview and record review on 11/1/2023 at 2:45 p.m. with LVN 3, LVN 3 reviewed Resident 38's Ativan Medication Count Sheet and MAR for 10/2023. LVN 3 stated that she administered a dose of Ativan 0.5 mg to Resident 38 on 10/6/2023 at 10:00 a.m. but forgot to document the medication as administered on Resident 38's MAR for 10/6/2023. LVN 3 stated it was busy on 10/6/2023 and it slipped her mind to document in Resident 38's MAR that she administered a dose of Ativan to the resident. During an interview on 11/2/2023 at 9:40 a.m. with RN 1, RN 1 stated the importance of documenting in the MAR is to communicate to the team that a resident received a medication on a specific date and time. RN 1 stated if the medication was not documented in the MAR, then it is considered not given. RN 1 stated if the medication was documented as removed from the bubble pack and not documented as administered, then the medication could have been stolen. During a concurrent interview and record review on 11/2/2023 at 3 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 reviewed Resident 38's Ativan Medication Count Sheet and MAR for 10/2023. LVN 4 stated that she administered a dose of Ativan to Resident 38 on 12 occasions (10/1/2023 at 9:00 p.m., 10/4/2023 at 9:00 p.m., 10/7/2023 at 9:00 p.m., 10/8/2023 at 9:00 p.m., 10/12/2023 at 9:00 p.m., 10/13/2023 at 9:00 p.m., 10/19/2023 at 9:00 p.m., 10/20/2023 at 9:00 p.m., 10/24/2023 at 9:00 p.m., 10/29/2023 at 9:00 p.m., 10/30/2023 at 9:00 p.m., and 10/31/2023 at 9:00 p.m.) in 10/2023 and did document in Resident 38's MAR as administered. LVN 4 stated she knows she is supposed to document in the MAR, but she ran out of time and only signed Resident 38's Medication Count Sheet for Ativan. A review of the facility policy and procedure titled, Administering Medications, last reviewed 10/11/2023 indicated medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication. A review of the facility procedure titled, Documentation of Medication Administration, last reviewed 10/11/2023, indicated that the facility shall maintain a medication administration record to document all medications administered. A nurse shall document all medications administered to each resident on the residents MAR. Administration of medications must be documented immediately after it is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 21 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 38) was free from unnecessary psychotropic medication (medications capable of affecting the mind, emotions, and behavior) by failing to limit the duration of an as needed (PRN) order for Ativan (a controlled substance [medication with a high potential for abuse] used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) to 14 days. This deficient practice had the potential to result in adverse reaction or impairment in the resident's mental or physical condition. Findings: A review of Resident 38's admission Record indicated the facility admitted Resident 38 on 1/26/2023 with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination ) and neurocognitive disorder with Lewy Bodies (a form of progressive dementia [the loss of cognitive functioning ; thinking, remembering, and reasoning ; to such an extent that it interferes with a resident's daily life and activities] that affects a person's ability to think, reason, and process information), ataxic gait (lack of coordination), and repeated falls. A review of Resident 38's Minimum Data Set (MDS - an assessment and care screening tool) dated 8/5/2023 indicated the Resident 38 sometimes had the ability to make himself understood and sometimes had the ability to understand others. A review of Resident 38's physician orders dated 1/26/2023, indicated an order for Ativan 0.5 milligram (mg - a unit of measurement), give one tablet by mouth every eight hours as needed for anxiety manifested by restlessness leading to exhaustion. During a concurrent interview and record review on 11/1/2023 at 9:45 a.m., with the Infection Preventionist (IP), Resident 38's physician orders for Ativan 0.5 mg dated 1/26/2023 was reviewed. The IP stated Resident 38 had an order for Ativan PRN with no duration or stop date. The IP stated psychotropic medications such as Ativan should have a stop date and limited to 14 days. The IP stated psychotropic medication are ordered for 14 days because the resident should be assessed to see if the behavior manifestations justify continuing the order for Ativan as it has a high risk of side effects. A review of the facility policy and procedure titled, Psychotropic Medication Use, last reviewed 10/11/2023, indicated psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. The policy further indicated that PRN orders for psychotropic medication are limited to 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 22 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a resident received his Isosorbide (a medication used for high blood pressure that works by dilating [widens] blood vessels) medication for 12 days as ordered by the physician for one (Resident 112) of six sampled residents observed during medication administration. Residents Affected - Few This deficient practice had the potential to place Resident 112 at increased risk of experiencing adverse effects, such as uncontrolled blood pressure, from not receiving his blood pressure medication. Findings: A review of Resident 112's admission Record indicated the facility admitted Resident 112 on 10/19/2023 with diagnoses that included hypertension (HTN - high blood pressure) and atrial fibrillation (a type of arrhythmia, or abnormal heart rhythm, that causes the heart to beat irregularly). A review of Resident 112's physician orders dated 10/19/2023, indicated an order to administer Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Resident 112's bubble pack (a card that packages medication per dose within a transparent plastic bubble) medications with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated that she was unable to find the bubble pack for Resident 112's Isosorbide medication. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Registered Nurse 1 (RN 1) call the facility's contracted pharmacy and spoke with Certified Pharmacy Technician 1 (CPhT 1). CPhT 1 stated that Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/1/2023 at 2:36 p.m., during a concurrent interview and record review, reviewed Resident 112's Medication Administration Record (MAR- a report detailing the drugs administered to a resident by a healthcare professional) for 10/2023 and 11/2023 with LVN 2. LVN 2 stated that she along with the other licensed nurses had been signing that they had administered Resident 112's Isosorbide medication from 10/20/2023 to 11/1/2023, totaling 12 occurrences. When asked why LVN 2 never followed up with the pharmacy Resident 112's missing Isosorbide medication, LVN 2 stated she had mistaken Resident 112's Isosorbide medication for one of the resident's kidney medications. On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that if a resident's medication was not available, the licensed nurse should check the physician's order and follow up with the pharmacy so that the pharmacy can send the resident's needed medication. RN 1 stated Resident 112 could have possibly suffered from adverse effects such as a stroke (happens when there is a loss of blood flow to part of the brain) or uncontrolled blood pressure since the resident was not receiving his ordered blood pressure medication. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 23 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident, right medication, right dosage, right time, and right method of administration before giving the medication. A review of the facility's policy and procedure titled, Pharmacy Services Overview, last reviewed on 10/11/2023, indicated that the facility shall accurately and safely provide and obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the services of a licensed Pharmacist (a person who is professionally qualified to prepare and dispense medicinal drugs). Event ID: Facility ID: 555045 If continuation sheet Page 24 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure medication bubble packs (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) were not stored in an unlocked drawer in Nursing Station 2 for two of two sampled residents (Resident 26 and Resident 34) investigated for Medication Storage and Labeling. 2. Label one open vial (small container) of glucometer test strips (an absorbent strip that soaks up blood to be read by the glucometer [medical device used for determining the approximate concentration of sugar in the blood]) found in one of two medication carts (Nursing Station 2 Medication Cart) investigated during the facility task Medication Storage and Labeling. These deficient practices had the potential to result in residents or unauthorized personnel accessing Resident 26 and Resident 34's medications and had the potential to compromise the accuracy of glucometer tests strips readings resulting in inaccurate blood glucose (sugar) readings and mismanagement of diabetes mellitus (a chronic condition that affects the way the body processes blood glucose) in residents. Findings: 1. A review of Resident 26's admission Record indicated the facility admitted Resident 26 on [DATE] and readmitted Resident 26 on [DATE] with diagnoses that included hypertensive heart and kidney disease (damage to the heart and kidneys due to chronic elevated blood pressure [the force of the blood pushing on the blood vessel walls is too high]), with heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), schizoaffective disorder (a mental health condition with symptoms of schizophrenia [delusions - false belief or judgment about external reality; hallucinations - sensing things such as visions, sounds, or smells that seem real but are not; disorganized thinking] bipolar type (extreme mood swings), and hyperlipidemia (high levels of fat in the blood). A review of Resident 26's Minimum Data Set (MDS - an assessment and care screening tool) dated [DATE] indicated Resident 26 usually had the ability to make himself understood and usually had the ability to understand others. A review of Resident 26's physician orders indicated orders for the following: a. Isosorbide Dinitrate (a medication to treat heart failure) oral tablet 10 milligrams (mg - a unit of measurement), give one tablet by mouth two times a day for coronary artery disease (a condition where the arteries [blood vessels] of the heart cannot deliver enough oxygen-rich blood to the heart), dated [DATE]. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 25 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hydralazine (a medication to treat high blood pressure) oral tablet 25 mg, give one tablet by mouth three times a day for hypertension (HTN - high blood pressure), dated [DATE]. c. Seroquel (a medication that treats mental health conditions) oral tablet give 200 mg by mouth at bedtime for schizophrenia manifested by agitation and irritability, picking fights with other residents, dated [DATE]. d. Atorvastatin Calcium (a medication to treat high cholesterol) oral tablet 20 mg, give one tablet by mouth at bedtime for hyperlipidemia (an abnormally high concentration of fats in the blood), dated [DATE]. A review of Resident 34's admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things that once brought joy) and schizophrenia. A review of Resident 34's MDS dated [DATE] indicated Resident 34 had the ability to make herself understood and had the ability to understand others. A review of Resident 34's physician orders dated [DATE], indicated an order for Risperidone (a medication to treat mental health conditions) oral tablet 0.5 mg, give one tablet by mouth at bedtime for schizophrenia manifested by hallucinations talking to unseen people. During a concurrent observation and interview on [DATE] at 3:45 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the following medication bubble packs were in an unlocked desk drawer in Nursing Station 2: a. Isosorbide Dinitrate 10 mg, with one tablet remaining for Resident 26. b. Hydralazine 25 mg with one tablet remaining for Resident 26. c. Seroquel 200 mg with four tablets remaining for Resident 26. d. Atorvastatin Calcium 20 mg with three tablets remaining for Resident 26 e. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 26 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Risperidone 0.5 mg with two tablets remaining for Resident 34. Level of Harm - Minimal harm or potential for actual harm LVN 3 stated she did not know why or for how long the five (5) medication bubble packs were kept in the unlocked drawer at the nursing station. LVN 3 stated somebody must have removed the bubble packs from the medication cart and forgot they put them in the desk drawer. LVN 3 stated the bubble packs should not have been in an unlocked drawer and should have been kept in a secured and locked area like a medication cart. LVN 3 stated medication should always be kept in a secure area to ensure medications do not go missing and that other staff and residents do not have access to them. Residents Affected - Some During an interview on [DATE] at 9:40 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that the facility's policy and procedure for medication storage was not followed because medications were left in an unlocked drawer when they should be stored in a secure and locked compartment. A review of the facility's policy and procedure titled, Storage of Medications, last reviewed [DATE] indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments. 2. During a concurrent observation and interview on [DATE] at 7:48 a.m. with LVN 3, Nursing Station 2 Medication Cart was observed. Observed one open glucometer test strip bottle with no labeled open date (when an item or medication is opened for the first time and the nursing staff document the date it was opened). LVN 3 stated test strips are labeled with the date opened because they expire one month after opening the vial. LVN 3 stated if expired test strips are used to measure a resident's blood sugar, it could result to an inaccurate reading. LVN 3 stated if the residents blood sugar is not measured accurately, then residents could be administered too much or too little insulin (a medication to treat high blood sugar) resulting in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and possible hospitalization. During a concurrent interview and record review on [DATE] at 9:40 a.m. with RN 1, RN 1 reviewed the facility's Glucose Test Strips User Instruction Manual. RN 1 stated diabetic resident's blood sugar readings are needed to determine the amount of insulin to administer. RN 1 stated the facility follows the manufacture guidelines and all glucometer test strips vial should be labeled with the open date. RN 1 stated the test strips expire three months after opening and should not be used once expired because it could lead to an inaccurate reading of a resident's blood sugar. RN 1 stated if an expired strip gives an inaccurate reading, it could result in resident's diabetes not being properly managed and possibly resulting in life threating issues like a diabetic coma (a life-threatening emergency causing loss of consciousness) or progression of their disease. A review of the facility's Glucose Platinum Test Strip User Instruction [NAME], dated 1/2021, indicated test strips are intended for the quantitative measurement of glucose in fresh capillary whole blood samples drawn from the fingertip as an aid to monitor the effectiveness of diabetes control. When you first open the vial, write the date on the vial label. Use the test strips within three months from first opening the vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 27 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food in accordance with professional standards for food service safety for 60 of 61 residents who receive food from the kitchen by: 1. Failing to ensure food items such as ham, cups of wild berry frozen desserts, lemons, apples, cheese, yogurt, and milk were labeled and dated with the received and/or open date (when staff write on the item the date it was received or the date it was first opened). 2. Failing to ensure the Meat Freezer temperature was maintained below 0 degrees Fahrenheit (?, a unit of measurement) for 16 of 31 logged temperature checks for 10/2023. 3. Failing to ensure the low temperature dishwashing machine (a device that applies water and a chemical sanitizing solution [destroys or prevents the growth of disease-causing microorganisms] to the surfaces of dishes and equipment) chlorine (a sanitizing solution) solution concentration (the amount of chemical dissolved in water) measured a minimum of 50 parts per million (ppm- a unit of measurement). 4. Failing to ensure there was an air gap (a fitting mounted about two inches (in - unit of measure) above the drain that prevents contaminated water from re-entering between the ice machine's drain hose (flexible tubing used to remove excess water from the ice maker and melted ice from the ice storage bin) and the floor drain (a plumbing fixture installed in the floor to remove standing water) to prevent backflow (reversal of normal direction of water) and contamination (the presence of harmful bacteria) of the machine's ice. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: 1. On 10/30/2023 at 7:52 a.m., during a concurrent observation and interview with the Dietary Supervisor (DS), the kitchen of the facility was observed. The DS stated the facility labels and dates all food items to ensure older items are used first and no expired foods are served to the residents. The DS stated the facility procedure for labeling is every food item is labeled with the date received and the date opened. The DS stated any food removed from its original packaging is also labeled with the item contents and date. Observed inside the facility kitchen alongside the DS were the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 28 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing (X3) DATE SURVEY COMPLETED A. Building 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 a. Level of Harm - Minimal harm or potential for actual harm Located in the Meat Freezer, one unopened frozen ham not labeled with the received date. The DS stated she did not know when the ham was received because it was not labeled with a received date. Residents Affected - Some b. Located in the Vegetable and Dessert's Freezer, one opened box containing 37 Magic Cup Wild Berry frozen desserts with no labeled received or opened date. The DS stated she did not know when the desserts were received or opened because it was not labeled. c. Located in the Walk-In Refrigerator, a plastic bin containing 12 lemons and six apples with no labeled received date. The DS stated all fruits and vegetables must be labeled with the date received. d. Located in the Walk-In Fridge, the following items were on an unlabeled tray: i. One unlabeled bowl possibly containing cheese. ii. Three unlabeled white Styrofoam cups possibly containing yogurt. iii. Eight unlabeled clear plastic cups possibly containing milk. The DS stated the items on the tray were leftovers from breakfast and should have been labeled with the item contents and dated, but they were not. During an interview on 10/31/2023 at 2:11 p.m., with the DS, the DS stated all foods should be labeled to ensure the First-In, First-Out method (a food rotation system used to ensure the item stored longest will be the next item used) of food is utilized. The DS stated the facility policy and procedures were not followed for refrigerator and freezer food storage. A review of the facility policy and procedure titled, Procedure for Freezer Storage, last reviewed 10/11/2023 indicated all frozen food should be labeled and dated. A review of the facility policy and procedure titled, Procedure for Refrigerated Storage last reviewed 10/11/2023 indicated food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice. Leftovers will be covered, labeled, and dated. Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 29 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy and procedure titled, Leftover Foods last reviewed 10/11/2023 indicated leftover foods will be stored and served in a safe manner. Leftover foods are labeled and dated. 2. On 10/30/2023 at 7:52 a.m., during a concurrent interview and record review with DS, the facility's freezer temperature log for the Meat Freezer, dated 10/2023 was reviewed. The DS stated the Meat Freezer temperature log is completed by kitchen staff twice a day and should indicate a temperature of below 0 ?. The DS stated the temperature log indicated the freezer was above 0 ? on the following dates: a. On the 10/3/2023 p.m. shift, the temperature was one (1) ?. b. On the 10/5/2023 p.m. shift, the temperature was three (3) ?. c. On the 10/6/2023 p.m. shift, the temperature was six (6) ?. d. On the 10/7/2023 a.m. shift, the temperature was six (6) ?. e. On the 10/7/2023 p.m. shift, the temperature was seven (7) ?. f. On the 10/9/2023 p.m. shift, the temperature was four (4) ?. g. On the 10/11/2023 p.m. shift, the temperature was seven (7) ?. h. On the 10/14/2023 p.m. shift, the temperature was seven (7) ?. i. On the 10/15/2023 p.m. shift, the temperature was six (6) ?. j. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 30 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On the 10/16/2023 p.m. shift, the temperature was two (2) ?. Level of Harm - Minimal harm or potential for actual harm k. On the 10/17/2023 p.m. shift, the temperature was six (6) ?. Residents Affected - Some l. On the 10/21/2023 p.m. shift, the temperature was seven (7) ?. m. On the 10/22/2023 p.m. shift, the temperature was five (5) ?. n. On the 10/27/2023 p.m. shift, the temperature was five (5) ?. o. On the 10/28/2023 p.m. shift, the temperature was eight (8) ?. p. On the 10/29/2023 p.m. shift, the temperature was three (3) ?. The DS stated the Meat Freezer should always be below 0 ? to keep the stored foods frozen. During an interview on 10/31/2023 at 2:11 p.m., with the DS, the DS stated she is responsible for monitoring the Meat Freezer temperature log but didn't see the out of normal range temperatures in the log. The DS stated the facility's procedure as well as the instructions on the temperature log indicates that if the temperature is not within an acceptable range, facility staff is to note a comment or correction and report to the supervisor immediately. The DS stated she was not informed when the temperatures were outside of normal range. The DS stated if the freezer temperature is too high it can lead to the meat thawing (going from a frozen state to an unfrozen state). The DS stated thawed meat should never be refrozen due to food safety issues and possible bacteria growth. A review of the facility policy and procedure titled, Procedure for Freezer Storage last reviewed 10/11/2023 indicated the freezer should be maintained at a temperature of 0? or lower. 3. On 10/30/2023 at 7:52 a.m., during a concurrent observation and interview with DS, Dietary Services Aide 2 (DSA 2), and [NAME] 1, the kitchens low temperature dish washing machine was observed. The DS stated the facility uses a low temperature dish washing machine with chemicals to ensure sanitization of resident dishware and utensils, kitchen pots, pans, and other kitchen equipment. DSA 2 stated the dishes to the left of the machine, including a large metal can opener, had just been washed in the machine and were clean. Observed the DS use a Chem [NAME] Chlorine Test Strip (a strip of paper used to indicate the strength of chemicals in a solution, with the correct measurement being 50 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 31 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 100 ppm. indicating the dishes were sanitized) on the surface of the clean dishes and the remaining water in the dishwashing machine. The DS stated the strip measured 10 ppm. and indicated the low temperature dishwasher was not sanitizing. The DS ran the dishwashing machine again and rechecked the sanitization solution level. Observed the test strip read 10 ppm. The DS stated there was something wrong with the low temperature dish washing machine because it was not sanitizing. The DS stated she would call the company that services it. During an interview on 10/31/2023 at 2:11 p.m., with the DS, the DS stated the facility uses the manufacture guidelines for the low temperature dishwashing machine and all facility equipment should be working. The DS stated if kitchen equipment and dishes are not properly sanitized it could lead to bacteria growth and it is a food safety concern for residents who may become ill. A review of the facility's policy and procedure titled Dish Washers Operation Manuel, undated, indicated to close the doors to start the machine, the machine will automatically start and run through its cycle. Watch to ensure that the chemicals are delivered and stop during the cycle. Follow the directions on the litmus paper (a type of paper that changes color according to the chlorine solution concentration level) and test the water on the surface of the bottom of the dishware, the concentration should be 50 ppm. 4. During a concurrent observation and interview with the DS on 10/31/2023 at 2:30 p.m., observed the facility's ice machine located inside the Station 2 Storage Room. Observe the machine drain hose placed inside the floor drain with no air gap. The DS stated the Maintenance Director (MD) was responsible for the ice machine and she did not know what an air gap was. During a concurrent observation and interview on 10/31/2023 at 2:50 p.m. with the MD, the MD observed the facility ice machine located inside Station 2 Storage Room. The MD stated there was no air gap between the ice machine drain hose and the floor drain. The MD stated the hose was placed in the floor drain. The MD stated there should always be a three-inch gap above the floor drain and where the drain hose ends to prevent backflow of contaminated water from the drain into the ice machine if the drain becomes backed up. The MD stated the facility did not have a policy regarding air gaps, but it was a standard of practice based on the Health and Safety Code (laws covering subject areas of health and safety in California). A review of the facility's policy regarding air gap included California Health and Safety Code 114193.1, dated 7/1/2007, indicated 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 one inch. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 32 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain complete and accurate medical records for two of six sampled residents (Resident 112 and Resident 14) by: Residents Affected - Few 1. Failing to ensure licensed nurses did not sign on the Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) when a resident's Isosorbide (used for the management of angina [chest pain]) medication was not available during medication administration observation. 2. Failing to ensure a licensed nurse did not sign on the MAR when a resident's Apixaban (medication that helps to prevent blood clots) was not available during medication administration observation. These deficient practices resulted in Resident 112 and Resident 14's medical records being inaccurate and not in accordance with professional standards of practice; and had the potential to result in confusion regarding Resident 112 and Resident 14's condition and what care and services were provided to Resident 112 and Resident 14. Findings: 1. A review of Resident 112's admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including hypertension (HTN - high blood pressure) and atrial fibrillation (a type of arrhythmia, or abnormal heart rhythm, that causes the heart to beat irregularly). A review of Resident 112's Physician Orders indicated an order dated 10/19/2023 for Isosorbide 240 milligrams (mg- unit of measure) by mouth (PO) daily for HTN. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, Licensed Vocational Nurse 2 (LVN 2) stated that she gave Resident 112 his Isosorbide 240 mg yesterday (10/31/2023) at approximately 9:00 a.m. When LVN 2 was asked to show Resident 112's bubble pack (a card that packages medication per dose within a transparent plastic bubble) for Isosorbide, LVN 2 stated she could not find the bubble pack for Resident 112's Isosorbide. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, observed Registered Nurse 1 (RN 1) call the facility's contracted pharmacy and spoke with Certified Pharmacy Technician 1 (CPhT 1). CPhT 1 stated that Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/1/2023 at 2:36 p.m., during a concurrent interview and record review, reviewed Resident 112's MAR for 10/2023 with LVN 2. LVN 2 stated that she along with the other licensed nurses had been signing that they had administered Resident 112's Isosorbide medication from 10/20/2023 to 10/31/2023, totaling 12 occurrences. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 33 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 2 (RN 2) stated that if nurses signed their initials on the MAR, it meant that the medication was administered. RN 2 stated that nurses should not be signing the MAR if a medication was not given. RN 2 stated that, in this particular case, since nurses were signing that they had been administering Resident 112's Isosorbide medication from 10/20/2023 to 10/31/2023, Resident 112 could have suffered from adverse consequences from not receiving the medication, such as uncontrolled blood pressure or a stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed on 10/11/2023, indicated that administration of medication must be documented immediately after (never before) it is given. 2. A review of Resident 14's admission Record indicated the facility originally admitted Resident 14 on 7/18/2022 and readmitted Resident 14 on 8/22/2022 with diagnoses including right heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), muscle atrophy (the decrease in size and wasting of muscle tissue), atrial fibrillation, nonrheumatic mitral (valve) insufficiency (when the mitral valve does not close properly, allowing blood to flow backwards into the heart), difficulty in walking, and stenosis of coronary artery stent (blockage or narrowing in portion of the coronary artery treated with a stent [device implanted that keeps the artery from being clogged]). A review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/1/2023, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance from staff for transfers, walking in the room and in the corridor, locomotion (movement or the ability to move from one place to another) on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 14's Physician's Order, dated 8/23/2022, indicated to give one tablet of Apixaban 2.5 mg by mouth one time a day for atrial fibrillation. On 10/31/2023 at 9:03 a.m., during a medication administration observation, observed LVN 2 administering due medications to Resident 14. Observed an empty bubble pack for Resident 14's Apixaban medication. LVN 2 stated she ran out of the apixaban and would follow up with the pharmacy for it. On 10/31/2023 at 9:27 a.m., during a concurrent observation and interview with LVN 2, observing LVN 2 administer Resident 14's due medications. Observed LVN 2 sign her initials on the MAR for Resident 14 under 10/31 for apixaban. When asked why LVN 2 signed Resident 14's apixaban as given for 10/31/2023, LVN 2 stated she did not want to leave a space blank on Resident 14's MAR. LVN 2 stated that if Resident 14's apixaban medication is delivered later in the day, then she will give the medication to the resident. LVN 2 stated that if Resident 14's apixaban medication is not delivered, then she would circle her initials indicating that the medication was not given to the resident. On 11/2/2023 at 1:51 p.m., during an interview, RN 2 stated that if nurses signed their initials on a resident's MAR, it meant that the medication was administered. RN 2 stated that nurses should not be signing the MAR if a medication was not given. RN 2 stated if a medication is not available, then nurses should make a note entry, otherwise licensed nurses can get confused as to what has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 34 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 actually been administered to a resident. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Residents Affected - Few A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed on 10/11/2023, indicated that administration of medication must be documented immediately after (never before) it is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 35 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement infection control practices by: Residents Affected - Some 1. Failing to ensure a resident's oxygen tubing (connects to an oxygen source to deliver oxygen to a resident) was labeled with the date it was last changed and was kept off the floor for one (Resident 110) of five sampled residents investigated for infection control. 2. Failing to ensure that, the wound treatment nurse (Licensed Vocational Nurse 1 [LVN 1]), who was observed wearing two sets of gloves on at the same time, performed hand hygiene (washing of hands) when removing one set of gloves during a wound care dressing (sterile [free from germs] pad applied to a wound to promote healing and protect the wound from infection) change observation for two (Residents 47 and Resident 16) of five sampled residents investigated for infection control. 3. Failing to ensure that during a medication administration observation, Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before and after administering medications to two (Residents 13 and Resident 112) of five sampled residents investigated for infection control. These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: a. A review of Resident 110's admission Record indicated the facility originally admitted the resident on 10/19/2023 and readmitted the resident on 10/28/2023 with diagnoses including hypertension (high blood pressure) and diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated). A review of Resident 110's physician's order, dated 10/28/2023, indicated an order for oxygen at two (2) liters per minute (LPM) via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) as needed for shortness of breath. On 10/30/2023 at 9:48 a.m., during a concurrent observation and interview with LVN 1, observed Resident 110 asleep in bed. Observed Resident 110 receiving oxygen at 2.5 LPM via nasal cannula. Also observed was Resident 110's oxygen tubing was not labeled with the date it was last changed, and the oxygen tubing was observed to be on the floor. LVN 1 stated that Resident 110's oxygen tubing was on the floor and had no date on it to indicate when the oxygen tubing was last changed. LVN 1 stated the oxygen tubing should be labeled with the date it was last change and stated that excess tubing should be kept off the floor and inside a plastic bag to prevent contamination of the tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 36 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm On 11/2/2023 at 11:36 a.m., during an interview, the Infection Preventionist (IP) stated it was important to keep oxygen tubing off the floor because the floor is contaminated with bacteria and can cause infection to a resident. The IP stated it was important to label the tubing with the date of when it was last changed to ensure the licensed nurses are aware of when the tubing is due to be changed so that the resident always has a clean oxygen tube. Residents Affected - Some On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that oxygen tubing should be labeled with the date of when it was last changed. RN 1 stated the purpose of labeling the tubing is so that staff know when it was last changed and so that it can be changed weekly. RN 1 stated it was also important to keep oxygen tubing off the floor to ensure that it does not become contaminated with the dirt from the floor. RN 1 stated that if the tubing becomes contaminated, then the resident can possibly get an infection from the oxygen tubing. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 10/11/2023, indicated that after completing the oxygen setup or adjustment, the following information should be recorded - the date and time that the procedure was performed. b. A review of Resident 47's admission Record indicated the facility originally admitted Resident 47 on 2/8/2021 and readmitted Resident 47 on 9/10/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD - refers to group of diseases that cause airflow blockage and breathing-related problems) with lower respiratory infection, atrial fibrillation (an irregular heartbeat and rapid heart rhythm), elevated white blood cell count (a lab test that indicates a resident has an on-going infection). A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/9/2023, indicated Resident 47 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance from staff for walking in the room and in the corridor, locomotion (movement or ability to move from one place to another) on and off the unit, dressing, and toilet use. A review of Resident 47's Physician's Order, dated 9/10/2023, indicated that for Resident 47's neck mid tracheostomy (a surgically created hole [stoma] in the windpipe that provides an alternative airway for breathing) stoma site, cleanse with normal saline (NS - a mixture of sodium chloride [salt] and water), pat dry, then cover with dry dressing daily and as needed. On 10/30/2023 at 9:58 a.m., during an observation, observed LVN 1 performing a dressing change to Resident 47's tracheostomy site. Observed LVN 1 put on two pairs of gloves before removing the dirty dressing and cleaning Resident 47's tracheostomy site. Observed LVN 1 then remove the first layer of gloves and put on a new pair of gloves without performing hand hygiene between glove changes. On 10/31/2023 at 2:11 p.m., during an interview, LVN 1 stated that he wears two pairs of gloves when he does dressing changes. LVN 1 stated he keeps on his first pair of gloves on and only changes the second pair of gloves. LVN 1 stated he only performs hand hygiene before putting on both sets of gloves and after taking off both gloves. LVN 1 stated he should be performing hand hygiene in between changing gloves for infection control. On 11/2/2023 at 11:36 a.m., during an interview, the Infection Preventionist (IP) stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 37 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm expected her licensed nurses, during dressing changes, to perform hand hygiene before and after the procedure, between going from dirty to clean, and between changing gloves. The IP stated it was important to perform hand hygiene between changing gloves to ensure that the nurse is not introducing contaminants from the dirty dressing to the clean dressing. The IP stated doing so can potentially lead to the resident contracting an infection. Residents Affected - Some On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that, during dressing changes, nurses should be performing hand hygiene before and after the procedure and between changing gloves. RN 1 stated it was important to perform hand hygiene between changing gloves in order to kill the bacteria on your hands and prevent cross contamination between glove changes. RN 1 stated the resident's wound can become infected if the nurse does not perform hand hygiene. A review of the facility's policy and procedure titled, Dressings, Dry/Clean, last reviewed on 10/11/2023, indicated the following steps for wound care dressing changes: 1. Wash and dry hands thoroughly. 2. Put on clean gloves. Loosen tape and remove soiled dressing. 3. Pull glove over dressing and discard into plastic or biohazard bag (used to dispose of waste material that is potentially infectious or could be a threat to a person's health). 4. Wash and dry your hands thoroughly. 5. Put on clean gloves 6. Cleanse the wound with ordered cleanser. 7. Use dry gauze to pat the wound dry. 8. Apply the ordered dressing and secure with tape or bordered dressing per order. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 38 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Level of Harm - Minimal harm or potential for actual harm c. Residents Affected - Some A review of Resident 16's admission Record indicated the facility originally admitted Resident 16 on 2/22/2023 and readmitted Resident 16 on 4/5/2023 with diagnoses that included pressure-induced deep tissue damage (damage of underlying soft tissue from pressure) to the left heel. A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had severely impaired cognition and required extensive assistance from staff for dressing and toilet use. A review of Resident 16's Physician's Order, dated 9/28/2023, indicated that for Resident 16's left heel stage four [4] pressure injury (The most severe type of pressure injury [wound that is the result of prolong pressure over a bony area]. The skin is severely damaged, and the surrounding tissue begins to die [tissue necrosis]), cleanse with NS, pat dry, apply collagen (a protein responsible for healthy joints and skin elasticity) powder, and cover with a foam dressing (used to create a moist environment conducive to wound healing) every day shift one time a day. On 10/30/2023 at 10:24 a.m., during an observation, observed LVN 1 performing a dressing change for Resident 16's left heel wound. Observed LVN 1 put on two pairs of gloves before removing the dirty dressing and cleaning the site. Observed LVN 1 remove the first layer of gloves and put on a new pair of gloves without performing hand hygiene between glove changes. On 10/31/2023 at 2:11 p.m., during an interview, LVN 1 stated that he wears two pairs of gloves when he does dressing changes. LVN 1 stated he keeps on his first pair of gloves and only changes the second pair of gloves. LVN 1 stated he only performs hand hygiene before putting on both sets of gloves and after taking off both gloves. LVN 1 stated he should be performing hand hygiene in between changing gloves for infection control. On 11/2/2023 at 11:36 a.m., during an interview, the IP stated she expected her licensed nurses, during dressing changes, to perform hand hygiene before and after the procedure, between going from dirty to clean, and between changing gloves. The IP stated it was important to perform hand hygiene between changing gloves to ensure that the nurse is not introducing contaminants from the dirty dressing to the clean dressing. The IP stated doing so can potentially lead to the resident contracting an infection. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated that, during dressing changes, nurses should be performing hand hygiene before and after the procedure and between changing gloves. RN 1 stated it was important to perform hand hygiene between changing gloves in order to kill the bacteria on your hands and prevent cross contamination between glove changes. RN 1 stated the resident's wound can become infected if the nurse does not perform hand hygiene. A review of the facility's policy and procedure titled, Dressings, Dry/Clean, last reviewed on 10/11/2023, indicated the following steps: 1. Wash and dry your hands thoroughly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 39 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. Level of Harm - Minimal harm or potential for actual harm Put on clean gloves. Loosen tape and remove soiled dressing. 3. Residents Affected - Some Pull glove over dressing and discard into plastic or biohazard bag. 4. Wash and dry your hands thoroughly. 5. Put on clean gloves 6. Cleanse the wound with ordered cleanser. 7. Use dry gauze to pat the wound dry. 8. Apply the ordered dressing and secure with tape or bordered dressing per order. 9. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. d. A review of Resident 13's admission Record indicated the facility admitted Resident 13 on 1/3/2020 with diagnoses that included hypertension. A review of Resident 13's MDS, dated [DATE], indicated Resident 13 had intact cognition and required supervision from staff with bed mobility, transfers, locomotion on and off the unit, and toilet use. A review of Resident 112's admission Record indicated the facility admitted Resident 112 on 10/19/2023 with diagnoses including hypertension and atrial fibrillation. On 10/31/2023 at 9:03 a.m., observed LVN 2 performing medication administration for Resident 13 and Resident 112. LVN 2 was observed not performing hand hygiene before or after administering medications to Resident 13 and Resident 112. On 10/31/2023 at 9:27 a.m., during an interview, LVN 2 stated that she did not perform hand hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 40 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 before, after, and between giving medications to Resident 13 and Resident 112. Level of Harm - Minimal harm or potential for actual harm On 11/2/2023 at 11:36 a.m., during an interview, the IP stated that, during medication administration, nurses should perform hand hygiene before preparing the medications, before going into the residents' room, and before and after administering medications to each resident. The IP stated hand hygiene is important to keep from spreading germs among residents. Residents Affected - Some On 11/2/2023 at 1:51 p.m., during an interview, RN 1 stated that, during medication administration, nurses should perform hand hygiene before and after each resident interaction so that they do not spread bacteria among the residents. A review of the facility's policy and procedure titled, Administering Medications, last reviewed on 10/11/2023, indicated that staff should follow established facility infection control procedures (e.g. handwashing, aseptic technique [practices and procedures that helps protect patients from dangerous germs], gloves, isolation precautions used to help stop the spread of germs from one person to another] etc.) for the administration of medications, as applicable. A review of the facility's policy and procedure titled, Standard Precautions (minimum infection prevention and control practices that must be used at all times for all residents in all situations), last reviewed on 10/11/2023, indicated that hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water before and after contact with the resident and after contact with items in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 41 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed ensure that 15 of 28 resident rooms met the square footage requirement of 80 square feet (sq. ft. - unit of measure) per resident. Residents Affected - Some This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident. Findings: On 10/30/2023, the Administrator (ADM) submitted the Client Accommodation Analysis Form (a form designed to provide a record of resident accommodations approved for licensed care) and the facility letter requesting for continuation of its room waiver. A review of the Client Accommodation Analysis Form indicated that 15 of 28 resident rooms did not have at least 80 square feet per resident. The Room Waiver Request Form and Client Accommodation Analysis Form indicated the following: Room No. Square Footage Bed Capacity Sq. Ft. per Resident 1 156 2 (two) 78 2 156 2 (two) 78 7 228 3 (three) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 42 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 76 Level of Harm - Potential for minimal harm 8 228 Residents Affected - Some 3 (three) 76 9 228 3 (three) 76 10 228 3 (three) 76 11 228 3 (three) 76 12 228 3 (three) 76 14 228 3 (three) 76 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 43 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 15 Level of Harm - Potential for minimal harm 228 3 (three) Residents Affected - Some 76 16 228 3 (three) 76 17 228 3 (three) 76 18 228 3 (three) 76 19 228 3 (three) 76 21 228 3 (three) 76 During a follow-up interview with the ADM, the ADM stated there should be at least 80 square feet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555045 If continuation sheet Page 44 of 45 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete per resident in multiple resident rooms. The minimum requirement for two residents (two bed) in a room should be at least 160 square feet and for three residents (three bed) in a room should be at least 240 square feet. On 11/1/2023 at 1:23 p.m., during a general observation, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had enough space to safely provide care to the residents with space for the beds, side tables, dressers, and resident care equipment. Residents who were in these rooms with limited size were not adversely affected. Event ID: Facility ID: 555045 If continuation sheet Page 45 of 45