Health inspection·January 23, 2024

F 0558 12 stated the facility seemed short staffed. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 12 was initiated on 1/9/24. Resident 12 was readmitted to the facility on [DATE]. Residents Affected - Some Review of Resident 12 ' s MDS dated [DATE], showed Resident 12 was cognitively intact, required partial/moderate assistance from staff for toileting hygiene, and was frequently incontinent for bowel and bladder. 3.a. On 1/9/24 at 1032 hours, an interview was conducted with Resident 2. Resident 2 was observed in bed and the call light was not observed to be next to him. Resident 2 stated he was almost 100% dependent on the facilitystaff to assist him with ADL care and could not do much of anything. Resident 2 stated he used a soft touch call light and it needed to be next to his head to call the facility staff for assistance. Resident 2 stated the call light was on his bed; however, the call light was next to his shoulder. Resident 2verified the call light was not within his reach and could not call for help. Resident 2 stated he needed to use his phone to call the facility staff for assistance if his call light was not within reach. Resident 2 stated it would sometimes take one hour or more for someone to answer the call light and provide assistance. Resident 2 stated he felt anxious, worried, and insignificant when asked about how long he waited to be assisted. On 1/9/24 at 1035 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 2 ' s call light was not within Resident 2 ' s reach. CNA 1 was then observed to move the call light next to Resident 2 ' s chest. Medical record review for Resident 2 was initiated on 1/9/24. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2 ' s MDS dated [DATE], showed Resident 2 was cognitively intact, was dependent on staff for mobility, and was always incontinent for bowel and bladder. Review of Resident 2 ' s plan of care showed a care plan focus dated 11/7/23, addressing Resident 2 ' s potential for pressure ulcer development. The approach plan showed an intervention to have Resident 2 ' s call light within reach. b. On 1/11/24 at 2059 hours, a follow-up interview was conducted with Resident 2. Resident 2 was asked about care and services received in the facility. Resident 2 stated the facility often did not answer call lights, especially when the registry staff worked. Resident 2 stated he would use the cell phone to call the facility ' s phone to get help, but nobody would answer. Resident 2 stated he needed help with changing because he was incontinent. Medical record review for Resident 2 was initiated on 1/11/24. Resident 2 was admitted to the facility on [DATE], and readmitted [DATE]. Review of the MDS dated [DATE], showed Resident 2 was cognitively intact, always incontinent of bowel and bladder, and dependent on staff for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after using toilet, commode, bedpan, or urinal). On 1/12/24 at 0923 hours, a follow-up interview was conducted with Resident 2. Resident 2 was asked how long he waited for assistance after using the call light. Resident 2 stated he had waited up to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 2 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7 hours during the night (2300 to 0700 hours) shift. Resident 2 stated there were times he had to sit in his stool, and it made him feel uncomfortable and caused pain. 4. On 1/9/24 at 0943 hours, Resident 7 was observed in bed. Resident 7 stated she was waiting for her CNA to change her diaper and clothes. Resident 7 stated she used the call light to ask for help but did not know where the call light was. Resident 7 ' s call light was observed to be clipped to the wall behind the resident ' s bed and not within Resident 7 ' s reach. On 1/9/24 at 0953 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 unclipped the call bell located on the wall behind Resident 7 ' s bed and handed it to Resident 7. Resident 7 then pressed the call light. LVN 3 stated she moved the call light next to Resident 7 and stated the call light should be within Resident 7 ' s reach. Medical record review for Resident 7 was initiated on 1/9/24. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7 ' s MDS dated [DATE], showed Resident 7 was cognitively intact, was dependent on staff for mobility, and was always incontinent for bowel and bladder. Review of Resident 7 ' s plan of care showed a care plan focus dated 1/18/23, addressing Resident 7 ' s risk for falls. The approach plan showed an intervention to have Resident 7 ' s call light within reach and encourage her to use it to call for assistance as needed. 5. On 1/9/24 at 0957 hours, Resident 4 was observed in bed. Resident 4 stated he needed help to get dressed, bathe, and to eat sometimes; and would use the call light but did not know where it was. Resident 4 ' s call light was observed hanging in between the siderail and the bed and not within his reach. Resident 4 stated he had to wait for someone to show up before getting any assistance. On 1/9/24 at 1004 hours, a concurrent observation and interview was conducted with RN 1 and CNA 1. RN 1 and CNA 1 acknowledged the above findings. CNA 1 stated the call light should be within Resident 4 ' s reach. Medical record review for Resident 4 was initiated on 1/9/24. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4 ' s MDS dated [DATE], showed Resident 4 required partial/moderate assistance from staff for bed mobility and was always incontinent for bowel and bladder. Review of Resident 4 ' s plan of care showed a care plan focus dated 5/15/19, addressing Resident 4 ' s risk for falls. The approach plan showed an intervention to have Resident 4 ' s call light within reach and encourage him to use it to call for assistance as needed. On 1/18/24 at 0631 hours, an interview was conducted with CNA 2. CNA 2 stated they were short staffed on weekdays and weekends; and when they were short, he would have 28 to 30 assigned residents to take care of. CNA 2 stated this would happen five out of seven days in a week. On 1/18/24 at 0641 hours, an interview was conducted with LVN 7. LVN 7 stated on a normal day, the facility staffed two or three LVNs and she would have 50 to 60 residents. LVN 7 stated she felt overwhelmed when she had that many residents and the residents would have to wait longer for care to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 3 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some provided. LVN 7 stated it was not safe for the residents and staff. LVN 7 stated the residents complained they had to wait and if they werein their soiled diapers for a long time. 6. On 1/9/24 at 0920 hours, an interview with Resident 3 was conducted. Resident 3 stated she waited as long as two hours almost every day to get assistance from the facility staff. Resident 3 stated she had a mobile phone to check how long she waited. Resident 3 stated she activated her call light because she needed assistance to have her diaper changed, Resident 3 felt awful not having her diaper changed immediately. Medical record review for Resident 3 was initiated on 1/9/24. Resident 3 was admitted to the facility on [DATE],and readmitted to the facility on [DATE]. Review of Resident 3 ' s MDS dated [DATE], showed Resident 3 was cognitively intact. Further review of theMDS showed Resident 3 required substantial assistance with toileting, and frequently incontinent of bowel and bladder. 7. On 1/10/24 at 0810 hours, an interview with Resident 8 was conducted. Resident 8 stated on 1/9/24, during the night shift, no one answered his call light andassisted himto turn to his side. Resident 8 added that he sat on poo all night. Resident 8 further stated he did not get his scheduled medications at 2100 hours on 1/9/24. Medical record review for Resident 8 was initiated on 1/10/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8 ' s MDS dated [DATE], showed Resident was cognitively intact. Further review of the MDS showed Resident 8 required substantial assistance in rolling from left and right, and was occasionally incontinent of bowel. On 10/10/24 at 0810 hours, an interview with CNA 8 was conducted. CNA 8 stated she came to work this morning in Nursing Station B with all her assigned residents ' diaper soaking wet. CNA 8 further stated she feltbad for the residents because there was nothing they could do but wait. On 1/10/24 at 0918 hours, and interview with LVN 4 was conducted. LVN 4 stated when the facility was short staffed, she fell behind on providing care to the residents. LVN 4 stated the facility was short staffed especially during the weekends. During the times when the facility was short staffed, LVN 4 stated she gotoverwhelmed, was not able to answer call lights timely; and the residents had to wait longer because she was attending to other residents. LVN 4 added that for the facility staff to respond to the resident, that resident would sometime be soaking wet of urine for waiting too long. 8. On 1/12/24 at 0906 hours, an interview was conducted with Resident 25. Resident 25 was asked about the call light response time in the facility. Resident 25 stated it depended on who was working and how many residents the facility staff were assigned with; but generally, it was worse on the night shift (2300 to 0700 hours). Resident 25 stated he had to wait up to 2.5 hours for assistance. Resident 25 stated he had to call the facility ' s front desk to receive assistance. Resident 25 stated he needed assistance with hygiene, as he was not always continent. Medical record review for Resident 25 was initiated on 1/11/24. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 4 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the MDS dated [DATE], showed Resident 25 was cognitively intact, occasionally incontinent of urine, and dependent on staff for toileting hygiene. 9. On 1/12/24 at 1025 hours, an interview was conducted with Resident 26. Resident 26 was asked about the call light response time. Resident 26 stated she had waited about 3 hours for care during the night shift. Resident 26 stated she was incontinent of urine and was made to sit in her urine. Resident 26 stated she was practically crying and very upset. Resident 26 stated she knew how long it took because she looked at her cell phone. Resident 26 stated it was very uncomfortable to sit in her urine. Medical record review for Resident 26 was initiated on 1/12/24. Resident 26 was admitted to the facility on [DATE], and readmitted [DATE]. Review of the MDS dated [DATE], showed Resident 26 was cognitively intact and dependent on staff for toileting hygiene. Review of the POC (Point of Care) Response History for bladder and bowel continence showed Resident 26 was often incontinent of both urine and stool. 10. On 1/17/24 at 1242 hours, an interview was conducted with Resident 24. Resident 24 was asked about call light response time. Resident 24 stated she had to wait for assistance from 20 minutes all the way to two hours depending on who was working. Resident 24 said she knew how long it took because she looked at her cell phone. Resident 24 stated she had been left in a wet diaper before for nine hours and it made her feel like the staff did not have any compassion. Medical record review for Resident 24 was initiated on 1/17/24. Resident 24 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 24 was cognitively intact, frequently incontinent of urine and stool, and dependent on staff for toileting hygiene. Review of the plan of care showed a care plan problem dated 9/18/23, addressing the potential for bowel/bladder incontinence related to impaired mobility, resident remains frequently incontinent with her bowel/bladder and requires total assist with her toileting needs. The care plan interventions included to provide assistance with toileting needs. On 1/18/24 at 0622, an interview was conducted with CNA 15. CNA 15 was asked if she was always able to get her work done and answer the call lights. CNA 15 stated when there were lots of patients assigned to her and the facility staff could not answer the call lights timely. Cross reference to F725. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 5 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 29 sampled residents (Resident 3) was provided the right to self-determination and communication regarding the changes of Resident 3 ' s Social Security Income (provides monthly payments to people with disabilities and older adults who have little or no income or resources) collection. This failure had the potential to affect Resident 3 ' s quality of life. Findings: Medical record review for Resident 3 was initiated on 1/9/24. Resident 3 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of Resident 3 ' s History and Physical examination dated 10/25/23, showed Resident 3 had the capacity to understand and make decisions. Review of Resident 3 ' s MDS dated [DATE], showed Resident 3 was cognitively intact. On 1/9/24 at 0920 hours, an observation and concurrentinterview were conducted with Resident 3. Resident 3 was observed in her room, awake, lying in her bed. Resident 3 stated she had been receiving money from SSI on a monthly basis and the money had been directly deposited to her personal bank account. Resident 3 stated she was surprised to check that no money was deposited to her account from the SSI for December 2023. Resident 3 stated when she spoke with an SSI representative, she was informed that her money was being deposited to the facility. Resident 3 stated she felt pissed off not receiving her moneyand for not being informed about the changes. Resident 3 further acknowledged her delinquency on her outstanding balance from the facility. Review of the SSA, Retirement, Survivors, and Disability Insurance letter dated 10/10/23, showed the facility hadbeen chosen to be Resident 3 ' s representative payee (a representative who manages the payments on behalf of the beneficiaries). The SSA, Retirement, Survivors, and Disability Insurance record further showed the facility wasreceiving Resident 3 ' s SSIbenefit payments since September 2023. On 1/9/24 at 1015 hours, an interview and concurrent record review was conducted with the Business Office Director and Business Office Assistant. The Business Office Director and Business Office Assistant were unable to provide documentation to show the facility provided notification to Resident 3 that her SSI payments had been changed to be deposited to the facility ' s account instead of Resident 3 ' s personal bank account. Review of the facility ' s Collections Statement for Resident 3, as of 1/9/24 at 1001 hours, showed the amounts of $2,494.00 on 10/11/23, $2,459.00 on 11/10/23, $2,459.00 on 1/6/24, and $2,573.00 on 1/8/24,were credited towards Resident 3 ' s outstanding payment from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 6 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) and advance directives information were accurate for four of 29 sampled residents (Residents 1, 2, 3, and 22) and one nonsampled resident (Resident B). These failures had the potential for the facility to provide treatment and services against the resident's wishes. Findings: Review of the facility's P&P titled Advance Directives revised 11/2019 showed the facility will be utilizing the POLST form for the residents with the capacity to make decisions and legal representatives to communicate their choices of medical interventions and procedures and end-of-life decisions if they wish to formulate an Advance Directive. Should the Resident indicate that he or she has issued advance directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record. 1.a. Closed medical record review was initiated for Resident 1 on [DATE]. Resident 1 was readmitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's H&P Examination dated [DATE] showed Resident 1 did not have the mental capacity to make informed decisions. Review of Resident 1's POLST, dated [DATE], showed Resident 1 had no advance directives. However, further review of Resident 1's medical record showed the Advance Healthcare Directive dated [DATE], showing Resident 1 had a Durable Power of Attorney for Health Care. The document was uploaded to the facility's electronic medical record system on [DATE]. On [DATE] at 1210 hours, a concurrent interview and medical record review was conducted with SSD 1. SSD 1 stated the POLST was updated upon admission and as needed and should be completed within the first three to seven days of admission. SSD 1 verified Resident 1's POLST dated [DATE], was not accurate to show Resident 1 had an advance directive in place and stated the IDT was responsible to make sure the POLST was accurate. SSD 1 stated the POLST should be available in the chart. b. Review of Resident 1's Progress Notes dated [DATE], showed Resident 1 was found to be unresponsive at 2035 hours. The Progress Note further showed Resident 1 was verbal and vocal at 2015 hours, according to LVN 8. RN 1 arrived at the bedside at 2035 hours, and assessed Resident 1. Vital signs were attempted, and no blood pressure, pulse or respiratory rate were present. CPR (cardiopulmonary resuscitation) was initiated and emergency services were called at 2040 hours. On [DATE] at 1010 hours, an interview was conducted with RN 4 regarding the above event which occurred on [DATE]. RN 1 stated they immediately began to initiate CPR and called emergency services. RN 4 stated he went to Resident 1's medical record to see the POLST for the measures, but the POLST was blank and did not show Resident 1's code status (type of resuscitation procedures the resident or their responsible party would like the healthcare team to conduct if the resident's heart stopped beating or the resident stopped breathing). RN 4 stated he treated Resident 1 as a full code (all resuscitation procedures will be provided to keep a person alive). RN 4 stated he informed Responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 7 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Party 1 that the POLST was blank; and knowing she was the DPOA for healthcare, he wanted to confirm her wishes and Responsible Party 1 stated to perform CPR. On [DATE] at 1332 hours, an interview was conducted with LVN 8. LVN 8 stated on the night of [DATE], Resident 1 was placed on an hourly visual check and LVN 8 kept an eye on Resident 1 because he kept crawling out of his bed. LVN 8 stated Resident 1 was yelling, cursing, and crying out for his daughter; and then heard him stop crying out for his daughter. LVN 8 stated he checked and found Resident 1 on the floor unresponsive around 2000 hours. LVN 8 stated he called the family member for the POLST because it was not signed and got confirmation Resident 1 was a full code. 2. Medical record review for Resident 2 was initiated on [DATE]. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 was cognitively intact. Review of Resident 2's POLST (undated) showed a physician's signature dated [DATE]; however, there was no information filled out on the POLST form. Additionally, there was no resident identifier to know who the physician had signed the POLST for. On [DATE] at 1241 hours, an interview and concurrent medical record review was conducted with SSD 1. SSD 1 reviewed Resident 2's medical record and verified there was no POLST or advance directive available in Resident 2's medical record and verified they should be in the medical record. On [DATE] at 1255 hours, a concurrent interview and medical record review was conducted with the ADON and SSD 1. The ADON stated she looked at Resident 2's medical record and the POLST was not completed. The ADON verified the POLST was left blank with a physician's signature. 3. On [DATE] at 0746 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated on admission, her responsibility would be the admission packets and consents. RN 1 showed Resident B's medical record to explain what the admission packet and consents were. Upon review, Resident B's POLST was observed to be in the medical record with no information filled out on the POLST form except for a physician's signature dated [DATE]. There was no resident identifier to know who the physician had signed the POLST for. RN 1 verified the findings and stated it should be filled out immediately soon after the resident's admission. Medical record review for Resident B was initiated on [DATE]. Resident B was readmitted to the facility on [DATE]. Review of Resident B's H&P Examination dated [DATE], showed Resident B had the capacity to understand and make decisions. 4. Medical record review for Resident 3 was initiated on [DATE]. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 3 was cognitively intact. Review of Resident 3's medical record failed to show documentation Resident 3 was provided with written information regarding advance directives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 8 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 0920 hours, an interview was conducted with Resident 3. When asked if she had an advance directive, Resident 3 stated she did not know. When asked if the staff had provided her with information regarding advance directives, Resident 3 stated no. On [DATE] at 1210 hours, an interview and concurrent medical record review for Resident 3 was conducted with the SSD. The SSD stated an advance directive showed the resident's wishes regarding medical care and treatment should the resident become incapacitated to make decisions in the future. The SSD verified there was no documentation to show Resident 3 was provided with written information regarding advance directives or how to formulate one. On [DATE] at 1051 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified no documentation regarding advance directives had been discussed with Resident 3. LVN 4 further verified a blank POLST was found in Resident 3's medical record with a physician's signature. LVN 4 verified the physician's signature belonged to Physician 1. Review of the facility's Signature Log for Certified Physicians and NP showed Physician 1 signed the blank POLST found in Resident 3's medical record. 5. Medical record review for Resident 22 was initiated on [DATE]. Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE]. Further review of Resident 22's medical record did not show a signed advance directive. Review of Resident 22's MDS dated [DATE], showed Resident 22 was moderately cognitively impaired. On [DATE] at 1552 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified there was no documented evidence the facility reached out to Resident 22's public guardian to notify them of Resident 22's admission and readmission on [DATE], and [DATE], and to discuss the resident's wishes. On [DATE] at 1101 hours, an interview was conducted with the Admissions Director. The Admissions Director stated if a resident was cognitively impaired, resident cannot be self-responsible to sign the admission consents, the facility should reach out to the responsible party to sign the legal documents pertaining to the resident's admission to the facility like consents and advance directive. The Admissions Director verified no consent nor advance directive was signed during Resident 22's admission to the facility on 10/23 and [DATE]. On [DATE] at 1400 hours, an interview with Resident 22's Public Guardian was conducted. The Public Guardian stated no one from the facility reached out to her regarding Resident 22's admission to the facility on 10/23 and [DATE], until [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 9 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the comfortable temperatures for six of 80 resident rooms (Rooms A, B, C, D, E, and F) housing 12 residents (Residents 2, 4, 17, 18, 23, 25, 27, E, F, G, H, and I). This failure had the potential for negatively affect the residents' health and well-being. Findings: Review of the facility's P&P titled Comfortable & Safe Air Temperature Levels revised 1/1/24, showed it is the policy of this facility to monitor, measure ambient air temperature and make sure the ambient temperature is comfortable and at a safe level, to minimize resident's susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailment. It will be the responsibility of the maintenance staff to monitor the ambient temperature of the resident's room and residents occupied area. Any temperatures that record below 71 degrees F (Fahrenheit) or exceed the upper range of 81 degrees F, the HVAC (heating, ventilation, and air conditioning) system will be adjusted to meet the resident comfortable and safe level. 1.a. On 1/11/24 at 2059 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 stated it was very cold and said the vent in his room would blow cold air. Resident 2 was observed laying under blankets in bed under the air vent. b. On 1/11/24 at 2110 hours, an observation and concurrent interview was conducted in Room E. Resident I was observed in bed with a blanket and thick comforter on. When asked if she was cold, Resident I nodded yes. c. On 1/11/24 at 2134 hours, an observation and concurrent interview was conducted with Resident 27. Resident 27 was observed wearing two shirts and a jacket with long jeans. Resident 27 stated it was always cold in the facility no matter the time of day. Resident 27 stated he was wearing layers because it was so cold, and he would prefer to be wearing something else. d. On 1/11/24 at 0820 hours, Resident 18 was observed sitting at the edge of his bed wearing a coat in Room F. There was no thermostat observed to be in Resident 18's room. Resident 18 verified the temperature in his room was too cold and stated he has told the facility staff about the cold temperature in his room many times, but they did not do anything. e. On 1/11/24 at 0833 hours, Resident 4 was observed in bed covered with three blankets in Room B. Resident 4 was asked if he was cold and his roommate, Resident 17, stated it felt cold as hell all the time. Resident 4 agreed with Resident 17 regarding the temperature of the room. Resident 4 stated the cold was uncomfortable and would happen day and night. On 1/11/24 at 0837 hours, Resident 17 stated he had five blankets on and would freeze at night. Resident 17 stated it was so cold, he would wear earmuffs so his ears do not get cold and felt like he was in Alaska. Resident 17 stated at night about 8 PM, it got bad and felt an uncontrollable freeze. 2.a. On 1/11/24 at 2152 hours, an observation was conducted with Maintenance Assistant 2. Maintenance Assistant 2 used the facility's temperature gun to measure the ambient temperature in Rooms A-F. The measurements were as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 10 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0584 - Room A was 69.6 degrees F, Level of Harm - Minimal harm or potential for actual harm - Room B was 68.9 degrees F, - Room C was 68.3 degrees F, Residents Affected - Few - Room D was 69.6 degrees F, - Room E was 70.7 degrees F; and - Room F was 67.6 degrees F. b. On 1/11/24 at 2200 hours, an interview was conducted with the Administrator. The Administrator was asked what the room temperatures should be in the resident rooms. The Administrator stated the temperatures should be between 71 and 81 degrees F. On 1/11/24 at 0815 hours, the thermostat in Nurse's Station C was observed to be off with no reading shown on the thermostat. The thermostat was observed to be covered by a clear lock box and was observed locked. On 1/11/24 at 0907 to 0926 hours, a concurrent observation and interview was conducted with Maintenance Assistant 1. Maintenance Assistant 1 stated they checked the resident room temperatures monthly and had not done the checks for January 2024 yet. Maintenance Assistant 1 stated the comfortable temperatures would be 71 degrees F at the lowest and 73 or 74 degrees F at the highest. Maintenance Assistant 1 stated he checked the temperatures with a temperature gun. Maintenance Assistant 1 was then asked to check the temperatures for Rooms F and B. For Room B, Maintenance Assistant 1 was observed using the temperature gun measuring the temperature in the middle of the room. The temperature reading was 66.9 degrees F. Maintenance Assistant 1 verified the temperature was cold and stated one thermostat controlled a few rooms. For Room F, the temperature reading was 67.1 degrees F. Maintenance Assistant 1 verified the temperature was cold. Maintenance Assistant 1 verified the thermostat in Nurse's Station A controlled the temperatures for three rooms and the whole hallway. Maintenance Assistance 1 verified the thermostat was off. Maintenance Assistant 1 stated he would need to check why the thermostat was off and verified only him and the Maintenance Supervisor had the keys to access and adjust the thermostat. Maintenance Assistant 1 verified if the thermostat was off, it would affect the temperature of the rooms and hallway. Maintenance Assistant 1 added he did not know how long it had been off. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 11 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the safe and appropriate discharge when one of 29 sampled residents (Resident 1) was discharged to another skilled nursing facility approximately 36.5 miles away. * The facility failed to ensure Resident 1 met the facility's criteria for discharge according to the facility's P&P. * The facility failed to document Resident 1's transfer information in the medical record. * The facility failed to ensure appropriate information was communicated to SNF 2 prior to the transfer of Resident 1. These failures had the potential of miscommunication of information, unsafe discharge, and not providing necessary care and services to the resident. Findings: Review of the facility's P&P titled Criteria for Transfer and Discharge revised 11/2016 showed it is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. The facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission, the facility may charge a resident only allowable charges under Medicaid; or, f. The facility ceases to operate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 12 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0622 Level of Harm - Minimal harm or potential for actual harm Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident 1's Order Summary Report dated 1/9/24, showed a physician's order dated 4/11/23, to transfer Resident 1to SNF 2 on 4/11/23. Residents Affected - Few Review of Resident 1's Progress Notes (written by RN 7) dated 4/11/23, showed Resident 1 was discharged to another facility (SNF 2) at 1620 hours. The Progress Notes also showed Resident 1 was picked up by transportation and a report was given to a nurse on duty. Further review of Resident 1's closed medical record failed to show any documented evidence of Resident 1 meeting the facility's discharge criteria and why the facility was transferring Resident 1 to another SNF. Furthermore, the review failed to show any documented evidence of a transfer record (a resident's medical information to ensure continuity of care) to SNF 2. Review of Resident 1's closed medical record from SNF 2 showed the resident was admitted to SNF 2 on 4/11/23. Review of Resident 1's admission Summary from SNF 2, dated 4/11/23, showed Resident 1 arrived at SNF 2 unexpectedly and arrived with transportation with only a driver in a car accompanying Resident 1. Resident 1 came into the facility walking with items of belongings in his hands. Resident 1 was very confused and very unsure of where he was. Resident 1 voiced no complaints of any pain or discomfort, no skin impairments, no shortness of breath or any acute distress. The admission Summary also showed the writer of the report spoke with RN 7 from the facility due to not having any report or any paperwork and received a limited report. On 1/9/24 at 1210 hours, an interview and concurrent closed medical record review was conducted with SSD 1. SSD 1 was unable to locate the documented evidence why Resident 1 was transferred to SNF 2 and verified the above findings. On 1/9/24 at 1555 hours, an interview and concurrent closed medical record review was conducted with the ADON. The ADON was unable to locate the documented evidence why Resident 1 was transferred to SNF 2and verified the above findings. Cross references to F623, F624, and F660. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 13 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to notify one of 29 sampled residents (Resident 1) and their representative of their transfer/discharge and the reasons for the move in writing. In addition, the facility failed to send a copy of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents). These failures resulted in Resident 1 and the representative to be not aware of the discharge. Findings: Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident 1's Order Summary Report, dated 1/9/24, showed a physician's order dated 4/11/23, to transfer to SNF 2 on 4/11/23. Review of Resident 1's Progress Notes (written by RN 7) dated 4/11/23, showed Resident 1 was discharged to another facility (SNF 2) at 1620 hours. The Progress Notes also showed Resident 1 was picked up by transportation and a report was given to a nurse on duty. Further review of Resident 1's closed medical record failed to show documented evidence Resident 1's responsible party was notified in writing prior to Resident 1's discharge on [DATE]. In addition, the facility failed to show documented evidence the Long-Term Care Ombudsman was notified of Resident 1's discharge to SNF 2. Review of Resident 1's medical record from SNF 2 showed the resident was admitted to SNF 2 on 4/11/23. Review of Resident 1's admission Summary from SNF 2 dated 4/11/23, showed a facility staff called Resident 1's responsible party (Responsible Party 1) to inform her of the resident being admitted to the facility about 1830 hours. The document showed Responsible Party 1 verbalized she was not aware of the transfer and never gave the permission or approval to the facility to transfer Resident 1 to SNF 2. The document further showed Responsible Party 1 verbalized the facility never called her prior to Resident 1'stransfer. Responsible Party 1 stated she would go to the facility and speak with them and call back. Review of Resident 1's Nursing note written by the ADON dated 4/11/23, showed Responsible Party 1 requested for Resident 1 to return back to the facility. Resident 1's physician was made aware of the request and agreed for Resident 1 to return. On 1/9/24 at 1210 hours, an interview and concurrent closed medical record review was conducted with SSD 1. SSD 1 was unable to locate the documented evidence Responsible Party 1 or Resident 1 was provided the notice before Resident 1 was transferred/discharged and verified the above findings. SSD 1 also verified a notice of transfer was not provided to the Office of the State Long-Term Care Ombudsman. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 14 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0623 Level of Harm - Minimal harm or potential for actual harm On 1/9/24 at 1555 hours, an interview and concurrent closed medical record review was conducted with the ADON. The ADON was unable to locate the documented evidence regarding notice of transfer/discharge and verified the above findings. Cross references to F622, F624, and F660. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 15 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide and document sufficient orientation and preparation to ensure the safe and orderly discharge for one of 29 sampled residents (Resident 1) prior to Resident 1's discharge to another healthcare facility, SNF 2. This failure resulted in Resident 1 and his responsible party of not having the necessary information for a safe and orderly discharge. Residents Affected - Few Findings: Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident 1's Order Summary Report dated 1/9/24, showed a physician's order dated 4/11/23, to transfer to SNF 2 on 4/11/23. Review of Resident 1's Progress Notes (written by RN 7) dated 4/11/23, showed Resident 1 was discharged to another facility (SNF 2) at 1620 hours. The Progress Notes also showed Resident 1 was picked up by transportation and a report was given to a nurse on duty. Further review of Resident 1's closed medical record failed to show documented evidence Resident 1 and his responsible party were provided sufficient preparation or notification regarding Resident 1 was being transferred to SNF 2. On 1/9/24 at 1210 hours, an interview and concurrent closed medical record review was conducted with SSD 1. SSD 1 was unable to locate the documented evidence the facility had prepared or informed Resident 1 or their responsible party of Resident 1 being transferred to another facility. SSD 1 verified the above findings. Cross references to F622, F623, and F660. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 16 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the comprehensive plans of care for two of 29 sampled residents (Residents 1 and 17) were revised to reflect the resident's current care needs and interventions. * Resident 1's plan of care was not updated to include all the fall interventions recommended by the IDT. * Resident 17's plan of care failed to show a care plan problem addressing the use of Seroquel. These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: 1. Review of the facility's P&P titled Fall Management System (undated) showed it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Review of the fall incident will include investigation to determine probably causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical of assistive devices that may be implicated in the fall. Resident existing care plan will be reviewed and updated by IDT. Closed medical record review was initiated for Resident 1 on [DATE]. Resident 1 was readmitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's H&P Examination dated [DATE],showed Resident 1 fell from standing the week prior and was sent to the hospital for a hip fracture. Resident 1 was readmitted to the facility [DATE], after hip surgery status post left hip hemiarthroplasty (joint replacement surgery). Shortly after, Resident 1 was sent to the acute care hospital and a CT angiogram of the chest showed bilateral lobar pulmonary embolism (blood clots in the lungs). Resident 1 was discharged back the facility [DATE], and on six months of PO Eliquis (blood thinner). The document also showed Resident 1 did not have the mental capacity to make informed decisions. Review of Resident 1's IDT Note dated [DATE], showed in part, the IDT met to discuss a plan of care status post fall on [DATE]. Resident 1 sustained a fall, after losing balance when walking in the hallway .Resident 1 returned to the facility on [DATE], with a diagnosis of left hip fracture. The IDT interventions included low bed, bilateral floor mats, PT/OT evaluation and treatment, and orthopedic follow up. Review of Resident 1's plan of care showed a care plan focus dated [DATE], addressing Resident 1's risk for falls. The approach plan failed to show other interventions, including bilateral floor mats and the orthopedic follow up. Review of Resident 1's Nursing note dated [DATE], showed Resident 1 was found lying flat on his back on the floor near the foot of the bed with his head towards the door of the room. Resident 1 was noted with skin tears to bilateral elbows. No other injuries noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 17 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0657 Level of Harm - Minimal harm or potential for actual harm On [DATE] at 0855 hours, an interview and concurrent closed medical record review was conducted with the ADON. The ADON stated an IDT for Resident 1's fall on [DATE], was entered on [DATE]. The ADON stated the IDT recommendations were for floor mats, low bed, PT/OT, and orthopedic follow up. The ADON verified Resident 1's plan of care failed to show all the fall interventions recommended by the IDT and needed to be revised to include all the updated interventions. Residents Affected - Few 2. According to Lexicomp (an online medication database), older patients have an increased risk of adverse reactions to antipsychotics (a medication used to treat certain types of mental health problem whose symptoms include psychotic experiences) and there is a black box warning about increased risk of death in older patients with dementia who are treated with antipsychotics. In light of this risk, and relative to their small beneficial effect in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic. Medical record review for Resident 17 was initiated on [DATE]. Resident 17 was admitted to the facility on [DATE], and readmitted [DATE],with diagnoses including dementia. Review of Resident 17's Order Summary Report showed an order dated [DATE], for Seroquel (an antipsychotic medication) oral tablet 50 mg, give one tablet by mouth at bedtime for hallucinations. Review of Resident 17's plan of care failed to show a care plan problem addressing the use of Seroquel. On [DATE] at 0744 hours, an interview and concurrent medical record review was conducted with LVN 13. LVN 13 reviewed Resident 17's medical record and verified Resident 17 had a physician's order for Seroquel; however, there was no care plan addressing the risks. Cross reference to F758 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 18 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop the discharge plan for one of 29 sampled residents (Resident 1) when Resident 1 was discharged to another healthcare facility, SNF 2. Subsequently, Resident 1 was discharged to another skilled nursing facility approximately 36.5 miles away. This failure had the potential to negatively impact the resident's well-being. Residents Affected - Few Findings: On 1/4/24 at 1538 hours, a telephone interview was conducted with Resident 1's responsible party (Responsible Party 1). Responsible Party 1 stated Resident 1 had lewy body dementia (disease which leads to problems with thinking, movement, behavior, and mood) and stated Resident 1 was an exit seeker and ambulatory. Responsible Party 1 stated the facility did not discuss a plan to indicate Resident 1 was going to another facility with her. Closed medical record review was initiated for Resident 1 on 1/9/24. Resident 1 was readmitted to the facility on [DATE], and discharged to SNF 2 on 4/11/23. Review of Resident 1's Order Summary Report dated 1/9/24, showed a physician's order dated 4/11/23, to transfer to SNF 2 on 4/11/23. Review of Resident 1's Progress Notes (written by RN 7) dated 4/11/23, showed Resident 1 was discharged to another facility (SNF 2) at 1620 hours. The Progress Notes also showed Resident 1 was picked up by transportation and a report was given to a nurse on duty. Further review of Resident 1's medical record failed to show documented evidence the facility formulated a discharge plan to transfer Resident 1 to SNF 2. On 1/9/24 at 1210 hours, an interview and concurrent closed medical record review was conducted with SSD 1. SSD 1 verified the above findings. SSD 1 was unable to locate the documented evidence of discharge planning for Resident 1's discharge or that the resident's responsible party was given the opportunity to participate in the discharge planning. On 1/9/24 at 1555 hours, an interview and concurrent closed medical record review was conducted with the ADON. The ADON verified the above findings. The ADON was unable to locate the documented evidence of discharge planning for Resident 1's discharge or that the resident's responsible party was given the opportunity to participate in the discharge planning. Cross references to F622, F623, and F624. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 19 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure eight of 29 sampled residents (Residents 1, 3, 6, 8, 9, 10, 13, and 22) and one nonsampled resident (Resident B) attained and maintained their highest practicable and physical well-being. Residents Affected - Some * The facility failed to provide the appropriate and necessary nursing services to ensure Resident 13 received daily wound treatments for his diabetic foot ulcer (a wound complication of diabetes which can cause bone infection and amputations) as per the physician's orders. In addition, the facility failed to evaluate Resident 13's skin upon admission and failed to implement weekly skin assessments as per the facility P&P. The facility additionally failed to ensure Resident 13's admission assessments were completed upon his admission to the facility. * The facility failed to ensure Resident B's readmission assessments and admission consents were completed upon her readmission to the facility on [DATE]. * The facility failed to ensure Resident 1's readmission assessments were completed timely upon readmission to the facility on [DATE] and [DATE]. In addition, the facility failed to ensure Resident 1 received the enoxaparin (blood thinner) medication as per the physician's orders. * The facility failed to follow the physician's order to administer Residents 6, 8, 9, 10, and 22's scheduled medications at 2100 hours on [DATE]. * The facility failed to ensure the content of the California Standard admission Agreement for Skilled Nursing Facilities (which contained information regarding resident bill of rights, financial arrangements, transfers/discharges, personal property, medical information confidentiality, facility rules, and facility grievance procedures) was provided and explained to the resident or resident's responsible party prior to or during the resident's admission to the facility for two of 22 sampled residents (Residents 3 and 22). This failure had the potential for Residents 3, and Resident 22's responsible party to be uninformed of the residents' rights during the time Resident 3, and Resident 22 resided in the facility. These failures had the potential for the residents to not receive the appropriate care and services for their medical conditions. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 12/2019 showed it is the policy of this facility that a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P also showed the following: * Resident assessment: the nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions - complete initial admission record and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time. Braden Scale should be completed on admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 20 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some * Skin and wound assessment on admission and readmission: a licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the Initial admission Record. A licensed nurse will assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or unusual findings, must be documented in the nursing notes or on the appropriate weekly assessment form. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. Review of the facility's P&P titled admission revised 5/2007 showed all admissions shall be assessed by the interdisciplinary health care team. The licensed nurse responsible for admitting the resident will complete the initial admission assessment within 24 hours of admission. Review of the facility's P&P titled Nutrition revised 5/2019 showed each resident's nutritional status is assessed on admission and at least quarterly thereafter. Review of the facility's P&P titled Fall Management System, undated, showed on admission, each resident is assessed using the Fall Risk Evaluation to determine his/her risk for fall. Review of the facility's P&P titled Pain Management, undated, showed the resident will be assessed for pain on admission with a pain-related diagnosis, or if pain is indicated. Complete the Pain Management Review is to be completed on admission, quarterly, and annually thereafter. Review of the facility's P&P titled Elopement/Unsafe Wandering revised 6/2018 showed Residents with capabilities of ambulation and/or mobility in wheelchair will have an Elopement/Wandering Evaluation completed to determine the risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 1.a. Medical record review for Resident 13 was initiated on [DATE]. Resident 13 was admitted to the facility on [DATE],with a primary diagnosis of acute osteomyelitis (infection of the bone) of left ankle and foot. Review of Resident 13's H&P Examination dated [DATE], showed Resident 13 had a left diabetic foot ulcer, and to continue the current treatment and medications and to see orders for details of plan. Further review of Resident 13's medical record failed to show a skin evaluation or Braden scale was completed upon Resident 13's admission on [DATE]. Review of Resident 13's Order Summary Report for [DATE] showed the physician's orders dated [DATE] (10 days after Resident 13's admission), for the following wound treatment: cleanse the left heel diabetic ulcer with normal saline, pat dry, apply medi-honey (an antibacterial gel used on wounds), and cover with a bordered gauze every day shift for wound healing. Review of Resident 13's Skin Evaluation - PRN/Weekly, dated [DATE] (10 days after Resident 13's admission to the facility), showed the skin assessment was completed by the treatment nurse and the resident had a diabetic heel wound to the left foot. The measurements were 4.5 cm (length) by 2.5 cm (width), and unable to determine depth. Review of Resident 13's Skin Ulcer Non-Pressure Weekly dated [DATE] (10 days after Resident 13's admission to the facility), showed an initial evaluation of Resident 13's left heel diabetic ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 21 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 The interventions included to provide treatment as ordered. Level of Harm - Minimal harm or potential for actual harm Further review of Resident 13's medical record failed to show a weekly skin evaluation was completed for Resident 13, except on [DATE]. Residents Affected - Some Review of Resident 13's TAR dated [DATE] and [DATE] showed the above wound care order: cleanse the left heel diabetic ulcer with normal saline, pat dry, apply medi-honey (an antibacterial gel used on wounds), and cover with a bordered gauze every day shift for wound healing. However, there were no license nurses' initials showing the wound care was provided on 12/29, [DATE], 1/24, 1/5, 1/6, 1/10, and [DATE]. On [DATE] at 1244 hours, an interview was conducted with Resident 13. When asked about his left foot, Resident 13 stated he had not been wearing appropriate shoes and got an infection. Resident 13 stated they treated his foot and came every other day but they did not come any more. On [DATE] at 1430 hours, a wound care observation of Resident 13's wound was conducted with LVN 5. After the wound care observation, LVN 5 was interviewed and verified the above findings. LVN 5 verified Resident 13 did not have a skin assessment completed upon admission and stated the assessment should be done within 48 hours of the resident's admission. In addition, LVN 5 verified there was no Braden scale completed upon admission or weekly wound assessments completed for Resident 13's wound. LVN 5 verified if there is no signature on the TAR, then the wound treatment was not done. LVN 5 verified Resident 13's treatments were not completed on the above listed dates. When asked about the missed wound treatments, LVN 5 stated there was difficulty with being the only treatment nurse on staff and he could have up to 80 residents with wound treatment orders if he was alone. LVN 5 stated he would prioritize if he was alone and would do all the treatments for pressure wounds, surgical wounds, diabetic wounds, and admissions; and the charge nurses were in charge of creams and GT dressings. Cross reference to F725. b. Further review of Resident 13's medical record failed to show admission assessments were completed within 24 hours upon Resident 13's admission on [DATE]. On [DATE] at 0746 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated on admission, her responsibility would be the admission packets and consents. RN 1 verified Resident 13 did not have an initial admission record, skin evaluation, pain management review, nutrition/hydration risk evaluation, elopement/wandering evaluation, admission drug regimen review, Braden Scale, or fall risk evaluation completed upon admission to the facility. RN 1 stated the admission assessments had to be done immediately. RN 1 stated there was only one RN in the daytime and she tried to do as much as she could. 2. Medical record review for Resident B was initiated on [DATE]. Resident B was readmitted to the facility on [DATE]. Review of Resident B's medical record failed to show the admission assessments and consents were completed within 24 hours of Resident B's readmission to the facility on [DATE]. Review of Resident B's H&P Examination dated [DATE], showed Resident B had the capacity to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 22 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 understand and make decisions. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 0746 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated on admission, her responsibility would be the admission packets and consents. RN 1 showed Resident B's medical record to explain what the admission packet and consents were. Upon review, Resident B's admission consent forms were observed in the medical record with no information filled out. The documents included a Physician's Order for Life Sustaining Treatment (POLST), Consent to Treat, inventory of Resident's Personal Belongings, Bed Hold Notification, Resident Informed Consent for COVID-19 Testing, and the Resident admission Influenza, Pneumococcal Vaccines Consent Form. RN 1 verified the findings and stated it should be filled out immediately soon after the resident's admission. RN 1 verified Resident B did not have an initial admission record, skin evaluation, elopement/wandering evaluation, admission drug regimen review, or fall risk evaluation completed within 24 hours upon readmission to the facility. Residents Affected - Some 3.a. Closed medical record review was initiated for Resident 1 on [DATE]. Resident 1 was readmitted to the facility on [DATE], discharged , then readmitted to the facility again on [DATE]. Resident 1 had expired on [DATE]. Review of Resident 1's medical record failed to show the admission assessments were completed within 24 hours of Resident 1's readmission on 12/9 and [DATE]. On [DATE] at 0855 hours, a concurrent interview and closed medical record review was conducted with the ADON. The ADON stated for admissions, the RNs would do the assessment, consents, and care plan for the residents. The ADON verified the above findings and verified they would need to complete the documentation within 24 hours of admission. b. Closed medical record review was initiated for Resident 1 on [DATE]. Resident 1 was readmitted to the facility on [DATE]. Resident 1 was sent to the acute care hospital on [DATE], due to bilateral lobar pulmonary embolism (blood clots in the lungs). Review of Resident 1's MAR for [DATE] showed Resident 1 had a physician's order dated [DATE], for enoxaparin sodium solution 40 mg/0.4 ml, inject 40 mg subcutaneously in the evening for prevent blood clotting. The order was placed on hold on [DATE], and discontinued on [DATE]. Further review of the MAR showed documentation of 7 on [DATE], which indicated on the MAR that 7 meant to see the nurses notes. Further review of Resident 1's closed medical record failed to show any nurses' notes regarding the reasoning as to why Resident 1 did not receive the enoxaparin medication on [DATE]. On [DATE] at 0855 hours, an interview and concurrent closed medical record review was conducted with the ADON. The ADON verified there was no documented evidence Resident 1 was administered the enoxaparin on [DATE], as ordered by the physician. 4. Review of the facility's P&P Preparation and General Guidelines dated 10/2019 showed the medications are administered in accordance with written orders of the attending physician. The medications are administered within (60 minutes time) of scheduled, except before or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescribed routine medications are administered according to the established medication administration schedule of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 23 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 Level of Harm - Minimal harm or potential for actual harm a. Medical record review for Resident 6 was initiated on [DATE]. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's H&P examination dated [DATE], showed a diagnosis of depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Residents Affected - Some Review of Resident 6's Order Summary Report as of [DATE], showed the following orders: - dated [DATE], to administer duloxetine HCl 60 mg by mouth at bedtime for depression manifested by verbalizing feeling depressed. - dated [DATE], to administer mirtazapine 15 mg by mouth at bedtime for depression manifested by inability to sleep. Review of Resident 6's MAR for [DATE] showed no documented evidence Resident 6 was administered duloxetine HCl 60 mg and mirtazapine 15 mg as ordered by the physician on [DATE] at 2100 hours. b. Medical record review for Resident 8 was initiated on [DATE]. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated [DATE], showed a diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), functional quadriplegia (complete immobility due to severe disability), polyneuropathy (when multiple peripheral nerves become damaged), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Review of Resident 8's Order Summary Report showed the following orders: - dated[DATE], to administer aripiprazole 10 mg by mouth at bedtime related to unspecified psychosis; - dated [DATE], to administer melatonin 10 mg by mouth at bedtime for insomnia; - dated [DATE], to administer docusate sodium 100 mg by mouth two times a day for bowel management; - dated [DATE], to administer Eliquis 5 mg by mouth two times a day for DVT (deep vein thrombosis, a blood clot in a deep vein, usually in the legs) prophylaxis; - dated [DATE], to administer gabapentin 300 mg by mouth every eight hours for neuropathy (weakness, numbness, and pain in the hands and feet); and - dated [DATE], to administer trazadone HCl 50 mg by mouth at bedtime for depression manifested by inability to sleep. Review of Resident 8's MAR for [DATE] showed no documented evidence Resident 8 was administered the above medications scheduled at 2100 hours on [DATE], as ordered by the physician. c. Medical record review for Resident 9 was initiated on [DATE]. Resident 9 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 24 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident 9's H&P examination dated [DATE], showed a diagnoses of finger osteomyelitis (inflammation of bone caused by infection), diabetes mellitus (high blood glucose), hypertension (high blood pressure), and hyperlipidemia (high level of fat particles in the blood). Review of Resident 9's Order Summary Report for [DATE] showed the following orders: Residents Affected - Some - dated [DATE], to administer atorvastatin calcium 80 mg by mouth at bedtime for hyperlipidemia. - dated [DATE], to administer topiramate 25 mg two times a day by mouth for migraines. - dated [DATE],to administer insulin lispro 100 unit/ml inject subcutaneously before meals and at bedtime as per sliding scale: if BS level 150-200 mg/dl = 2 units, 201-300 mg/dl = 4 units, 301- 400 mg/dl = 6 units, 401-500 mg/dl = 8units, and 501-600 mg/dl = 10 units, and call MD. - dated [DATE],to administer cefazolin sodium 1 gram intravenously every eight hours for osteomyelitis. - dated [DATE],to administer trazadone 50 mg by mouth at bedtime for depression manifested by inability to sleep. - dated [DATE],to administer buspirone HCl 5 mg two times a day by mouth for anxiety manifested by verbalization of feeling anxious. - dated [DATE],to administer pregabalin 75 mg two times a day by mouth for neurological pain. Review of Resident 9's MAR for [DATE] showed no documented evidence Resident 9 was administered the above oral medications scheduled at 2100 hours on [DATE], as ordered by the physician. Further review of Resident 9's IV MAR for [DATE] showed no documented evidence Resident 9 was administered the cefazolin sodium intravenously scheduled at 0600 hours on 1/5, 1/6, and [DATE], as ordered by the physician. d. Medical record review for Resident 10 was initiated on [DATE]. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated [DATE], showed a diagnosis of tremors (an involuntary, quivering movement), neuralgia (is a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), neuritis (an inflammatory or degenerative lesion of a nerve marked especially by pain), diabetes mellitus (high blood sugar), muscle weakness, hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood) Review of Resident 10's Order Summary Report for [DATE] showed the physician's orders dated [DATE], to administer the following medications: - atorvastatin calcium 20 mg by mouth at bedtime for lipidemia, - docusate sodium 250 mg by mouth at bedtime for bowel management, - melatonin 3 mg by mouth at bedtime for insomnia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 25 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 - apixaban 2.5 mg by mouth two times a day for DVT prophylaxis, Level of Harm - Minimal harm or potential for actual harm - gabapentin 300 mg by mouth every eight hours for neuropathy Residents Affected - Some Review of Resident 10's MAR for [DATE] showed no documented evidence Resident 10 was administered the above medications scheduled at 2100 hours on [DATE], as ordered by the physician. e. Medical record review for Resident 22 was initiated on [DATE]. Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 22's H&P examination dated [DATE], showed Resident 22 showed a diagnosis of anemia (blood lacks adequate healthy red blood cells), hypertension (high blood pressure), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), diabetes mellitus (high blood glucose) Review of Resident 22's Order Summary Report as of [DATE], showed the following orders: - dated [DATE], to administer Clorazil 100 mg by mouth at bedtime for schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). - dated [DATE], to administer Depakote ER 500 mg by mouth at bedtime for schizophrenia. - dated [DATE], to administer oxybutynin chloride 5 mg by mouth at bedtime for overactive bladder. - dated [DATE], to administer Zyprexa 5 mg by mouth at bedtime for schizophrenia. - dated [DATE], to administer methocarbamol 500 mg by mouth every eight hours for generalized pain. - dated [DATE], to administer oxycodone HCl 10 mg two tablets every eight hours for cancer related pain. - dated [DATE], to administer gabapentin 800 mg every eight hours for neurological pain. - dated [DATE], to administer valacyclovir HCl 1 gram by mouth every eight hours for HSV (herpes simplex virus, a virus causing contagious sores, most common around the mouth or on the genitals). - dated [DATE], to administer Restoril 15 mg by mouth at bedtime for insomnia (sleep disorder). - dated [DATE], to administer nortriptyline HCl 10 mg by mouth at bedtime for pain causation cancer. Review of Resident 22's MAR for [DATE] showed no documented evidence Resident 22 was administered the above medications scheduled at 2100 hours on [DATE], as ordered by the physician. On [DATE] at 1045 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified there were no documented evidence Residents 6, 8, 9, 10, and 22 were administered their medications as ordered. RN 5 further verified there was no documented evidence to show the physician was notified of the missed medications for these residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 26 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0684 Level of Harm - Minimal harm or potential for actual harm 5.a. Medical record review for Resident 3 was initiated on [DATE]. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 3 had a BIMS score of 13 (score of 13-15 suggests that cognition is intact). Residents Affected - Some Further review of the medical record showed Resident 3's California Standard admission Agreement for Skilled Nursing Facilities admission/readmission packet was not signed. b. Medical record review for Resident 22 was initiated on [DATE]. Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 22's H&P examination dated [DATE], showed Resident 22 had fluctuating capacity to understand and make decisions. On [DATE] at 0749 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified Residents 3 and 22's California Standard admission Agreement for Skilled Nursing Facilities did not contain the signatures the residents nor their responsible parties (indicating the contents of the admission agreement were discussed). RN 5 further verified there was no documented evidence the facility attempted to contact the responsible party for Resident 22 on 10/23 and [DATE] admissions. On [DATE] at 1101 hours, an interview and concurrent medical record review was conducted with the facility's Admissions Coordinator. The Admissions Coordinator stated upon admission to the facility, a determination was made as to whether a resident was self-responsible or had a designated responsible party. Once the responsible party was established, the facility then reviewed the California Standard admission Agreement with the responsible party. The admission Coordinator stated this review may be conducted in person or over the phone and would take place within two business days after a resident was admitted to the facility. The admission Coordinator stated if the facility was unable to review the California Standard admission Agreement with the responsible party (within two business days), attempts to do so would continue while the resident remained in the facility. The admission Coordinator stated the California Standard admission Agreement for Skilled Nursing Facilities defined the resident rights and obligations. The Admissions Coordinator further verified Residents 3 and 22 did not have a signed California Standard admission Agreement in file. Cross reference toF725. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 27 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medial record review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries for three of 29 sampled residents (Residents 14, 15, and 24). Residents Affected - Few * The facility failed to provide the appropriate and necessary nursing services to ensure Resident 14 received daily wound treatments for his Stage 4 pressure injury (a wound caused by pressure which results in tissue loss with exposed bone, tendon, or muscle) as per the physician's orders. * The facility failed to ensure Resident 15 received daily wound treatments for his Stage 4 pressure injury as per the physician's orders. * Resident 24 had a physician's order for a low air loss mattress (a special mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown); however, Resident 24 was observed on a regular mattress on multiple occasions. These failures had the potential for the residents to not receive the appropriate care and services to promote healing or prevent the development and worsening of pressure injuries. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 12/2019 showed it is the policy of this facility that a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. Review of the facility's P&P titled Skin Management System revised 5/2019 showed a plan of care will also be initiated to address areas of actual skin breakdown. The plan of care will be reviewed and revised as needed. 1. Medical record review for Resident 14 was initiated on 1/17/23. Resident 14 was readmitted to the facility on [DATE]. Review of Resident 14's Skin Pressure Ulcer Weekly dated 1/5/24, showed Resident 14 had a Stage 4 pressure injury at the sacro-coccyx present on admission. The interventions included to provide treatments as ordered. Review of Resident 14's Order Summary Report for January 2024 showed the physician's orders dated 12/21/23, to perform wound treatment for the resident's Stage 4 pressure injury as follows: clean with normal saline, pat dry, apply med-honey, apply calcium alginate (a type of wound dressing), and cover with an absorbent bordered gauze every day shift. Review of Resident 14's TAR for January 2024 showed no documented evidence the above wound treatment was provided to the resident on 1/1, 1/6, and 1/11/24. On 1/18/24 at 0729 hours, an interview was conducted with Resident 14. Resident 14 was observed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 28 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0686 Level of Harm - Minimal harm or potential for actual harm bed with a low-air loss mattress. Resident 14 stated he had a bed sore on his back side and the wound was treated every day. Resident 14 stated he had missed treatments about once a week. 2. Medical record review for Resident 15 was initiated on 1/17/23. Resident 15 was readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 15's Skin Ulcer Non-Pressure Weekly dated 1/15/24, showed Resident 15 had a left lower extremity venous stasis ulcer (a wound on the leg caused by problems with circulation in the leg veins) and moisture-associated dermatitis (skin damage/inflammation caused by prolonged exposure to moisture) to his sacral coccyx. The two wounds had an unknown onset and the interventions included to provide treatments as ordered. Review of Resident 15's Skin Pressure Ulcer Weekly dated 1/15/24, showed Resident 15 had a stable right buttock Stage 4 pressure injury and was seen by the provider for wound care. Review of Resident 15's plan of care showed a care plan problem addressing Resident 15's Stage 4 pressure injury. Review of Resident 15's Order Summary Report dated 1/17/24, showed the physician's orders for the following wound treatments: - For the right buttock Stage 4 pressure injury: cleanse with normal saline, pat dry, apply medi-honey and calcium Alginate and cover with dry dressing every day shift, ordered on 4/5/23. - For the left ischium healed Stage 4 pressure injury: cleanse with normal saline, pat dry, apply barrier cream, leave open to air, every day shift for maintenance, ordered on 12/5/23. - For the left lower extremity scattered peripheral vascular disease (PVD, a circulation disorder caused by narrowed blood vessels in the limbs) ulcers: cleanse with normal saline, pat dry, apply xeroform and collagen powder, cover with an abdominal pad and wrap with a gauze every day shift, every other day, ordered 8/17/23. - For the sacral coccyx MASD: apply barrier cream to clean dry skin and leave open to air every day shift for treatment, ordered on 10/2/23 Review of Resident 15's TAR for December 2023 and January 2024 showed no documented evidence the above wound treatments were provided on 12/2, 12/15, 12/16, 12/17, 12/18, and 12/20/23, 1/1, 1/2, 1/4, 1/5, 1/6, 1/11, and 1/12/24. On 1/17/24 at 1430 hours, a wound care observation of Resident 15's wound was conducted with LVN 5. After the wound care observation, LVN 5 was interviewed regarding the above findings. LVN 5 acknowledged and verified the above findings. LVN 5 verified Resident 15 did not have a care plan to address his pressure injury. LVN 5 verified if there was no signature present on the TAR, then the wound treatment was not done. When asked about the missed wound treatments, LVN 5 acknowledged there was difficulty with being the only treatment nurse on staff and he could have up to 80 residents with wound treatment orders if he was alone. LVN 5 stated he would prioritize if he was alone and would do all the treatments for pressure wounds, surgical wounds, diabetic wounds, and admissions; and the charge nurses were in charge of creams and GT dressings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 29 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0686 Cross reference to F725. Level of Harm - Minimal harm or potential for actual harm 3. On 1/17/24 at 1242 hours, Resident 24 was observed in bed lying on a regular mattress. Residents Affected - Few On 1/17/24 at 1510 hours, Resident 24 again was observed in bed, lying on her left side on a regular mattress. Medical record review for Resident 24 was initiated on 1/17/24. Resident 24 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 24's Order Summary Report showed an order dated 11/29/23, for a low air loss mattress. Review of Resident 24's plan of care showed a care plan problem dated 6/29/23, addressing the potential for pressure injury development related to impaired mobility. On 1/18/24 at 0651 hours, an observation, interview, and concurrent medical record review was conducted with RN 8. Resident 24 was observed on a regular mattress. RN 8 verified this finding and verified Resident 24 was not on a low air loss mattress but had a physician's order for one. RN 8 also verified Resident 24 was at risk for pressure injury development. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 30 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - Few 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 interview, medical record review, and facility P&P review, the facility failed to ensure three of 29 sampled residents (Residents 19, 20, and 21) remained free from accident hazards. * The facility failed to update a care plan to address the fall sustained by Resident 20 on 1/6/24, and Resident 21 on 12/15/23. * The facility failed to ensure the IDT had met and discussed the factors that lead to the fall and the intervention on how to prevent further falls for Resident 19 who sustained a fall on 1/6/24, Resident 20 who sustained a fall on 1/6/24, and Resident 21 who sustained a fall on 12/15/23. These failures had the potential for the residents to sustain additional falls and possible injuries. Findings: Review of the facility's P&P titled Nursing Administration, Section Continuum of Care, Subject Fall Prevention revised 8/2020 showed the following: a. Falls are reviewed in clinical stand-up meeting after the fall. b. Residents that will be reviewed by the Fall Interdisciplinary (ID) Team will be identified in the following ways: - All residents who have experienced a fall during the prior week. - Resident referred to the committee by nursing, social services, activities, rehabilitation services, physician and others. c. A Post Fall Assessment including recommendations and care plan changes will be completed for all residents who have experience a fall. With the purpose to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The procedures showed if appropriate, interventions will be initiated per ID Team member recommendations and when necessary, physician orders (i.e., Physical Therapy Services, initiation or modification of a device etc.) for any fall related incident. The falls ID Team will meet to complete the Post Fall Assessment, identify contributing factors, and make recommendations and care plan changes for all residents who have experiences a fall during the prior week. Discussion topics may include, but are not limited to the following: - apparent trigger of the fall - pattern of the fall (time, place, activity) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 31 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - recent medication changes Level of Harm - Minimal harm or potential for actual harm - medication status - mental status Residents Affected - Few - orthopedic and/or neuromuscular condition - changes in condition The IDT will generate recommendations which may include, but not limited to: - nursing interventions - falls assessment - medical follow up - physical therapy evaluation and treatment for seating and positioning, gait training, ect. - pain assessment Care plans will be revised and/or updated to reflect changes in intervention. 1. Medical record review for Resident 20 was initiated on 1/18/24 at 0651 hours. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's MDS dated [DATE], showed Resident 20 had a BIMS score of 5 (score of 0-7 suggests severe cognitive impairment). Review of Resident 20's Fall Risk Evaluation dated 12/6/23, showed Resident 20 was at high risk for fall. Review of Resident 20's Change in Condition Evaluation dated 1/6/24, showed Resident 20 had a fall in the afternoon of 1/6/24. Review of Resident 20's comprehensive plan of care did not show an update to address Resident 20's fall sustained on 1/6/24. 2. Medical record review for Resident 21 was initiated on 1/18/24. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's MDS dated [DATE], showed a BIMS score of 1 (score of 0-7 suggests severe cognitive impairment). Further review of the MDS showed Resident 21 was dependent with staff when moving from sitting to standing position. Review of Resident 21's Fall Risk Evaluation dated 12/15/23, showed Resident 21 was at high risk for fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 32 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 Review of Resident 21's Change in Condition Evaluation dated 12/15/23, showed Resident 21 had a fall on 12/15/23, sustaining a laceration above the right eyebrow. Review of Resident 21's plan of care did not show an update care plan to address Resident 21's fall on 12/15/23. Residents Affected - Few 3. Medical record review for Resident 19 was initiated on 1/18/24. Resident 19 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 19's MDS dated [DATE], showed a BIMs score of 15 (score of 13-15 cognitively intact). Review of Resident 19's Quarterly Fall Risk Evaluation dated 10/17/23, showed Resident 19 was a medium risk for fall. Review of Resident 19's Change in Condition Evaluation dated 1/6/24, showed Resident 19 was found sitting on the floor on 1/6/24, in the morning. The Change of Condition Evaluation showed Resident 19 stated she was organizing her belongings when she slid down from her wheelchair and fell on the floor. On 1/17/24 at 1424 hours, an interview and concurrent record review was conducted with RN 1. RN 1 stated when a resident sustained a fall, the facility's practice would be to document the incident through the change of condition, where the resident would be assessed post fall, and physician and family member would be notified. RN 1 also stated the IDT would meet to discuss what triggers the fall and how to prevent future falls, with the care plan being updated. RN 1 verified there was no documented evidence to show the IDT had met and discussed Residents 19, 20, and 21's falls, and verified Residents 20 and 21's care plans were not updated. On 1/18/24 at 0749 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified there was no documented evidence to show the IDT had met to identify Residents 19, 20 and 21's falls to discuss contributing factors to the fall, make recommendations, and update the care plan to prevent future falls. RN 5 further verified Residents 20 and 21's care plans were not updated. On 1/18/24 at 0855 hours, an interview and concurrent medical record review with the ADON was conducted. The ADON verified no documented evidence to show the IDT had met to identify Resident 19's fall on 1/6/34, Resident 20's fall on 1/6/24, and Resident 21's fall on 12/15/23, to discuss recommendations and care plan changes were completed and implemented actions to reduce the incidence of additional falls and minimize potential injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 33 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the proper indwelling urinary catheter care for one of 29 sampled residents (Resident 17). * Resident 17 was observed with an indwelling urinary catheter bag on the floor and/or attached to a trash can on multiple occasions. This failure put Resident 17 at risk for infection, such as UTI. Findings: According to the CDC guidelines, the proper urinary catheter maintenance includes keeping the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. On 1/9/24 at 1000 hours, Resident 17 was observed in bed with a urinary catheter bag. The urinary drainage bag was observed hooked to the top of Resident 17's trash can and with the drainage bag touching the floor. When asked about the urinary drainage bag, Resident 17 stated he had an operation and a nephrostomy (a drainage tube inserted into the kidney used to drain urine through an opening in the skin). On 1/9/24 at 1014 hours, a concurrent observation and interview was conducted with RN 1. RN 1 verified the urinary drainage bag was hooked to the top of Resident 17's trash can and touching the floor. RN 1 verified the urinary drainage bag should not be hooked on top of the trash can. RN 1 proceeded to move the urinary drainage bag to hang off the bed instead. On 1/11/24 at 0837 hours, Resident 17 was observed again with his urinary drainage bag hooked to the top of his trash can with the drainage bag touching the floor. During an observation at Resident 17's bedside on 1/17/24 at 1006 hours, Resident 17 was observed in bed with an indwelling urinary drainage catheter in place. The drainage bag was hanging on a trash receptacle to the right side of the bed and touching the floor. On 1/17/24 at 1008 hours, an observation and concurrent interview was conducted with LVN 12 at Resident 17's bedside. LVN 12 verified Resident 17's urinary catheter drainage bag was hanging on a trash receptacle and touching the floor. LVN 12 stated it was an infection risk. Medical record review for Resident 17 was initiated on 1/12/24. Resident 17 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident 17's Order Summary Report showed an order dated 1/17/24, to change urostomy bag as needed for leakage, accumulation of sediment, discoloration of the bag as needed. Review of Resident 17's urinary culture laboratory test results dated 1/21/24, showed Resident 17 had multiple bacteria in his urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 34 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to two of 29 sampled residents (Residents 10 and 23). Residents Affected - Few * The licensed nurse failed to notify the physician regarding Resident 10's complaint of pain level more than 6 and the resident's prescribed PRN pain medications were only for the pain levels of 1-6. * The facility failed to ensure the pain medication was given as ordered by the physician. Resident 23 waited six hours to receive the next pain medication dose. These failures resulted in the residents not receiving effective pain management. 1. Medical record review for Resident 10 was initiated on 1/10/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 11/13/23, showed diagnoses of tremors, neuralgia, neuritis, diabetes mellitus, muscle weakness, hypertension, and hyperlipidemia. Review of Resident 10's Order Summary Report for January 2024 showed an order dated 11/10/23, to administer acetaminophen 650 mg by mouth every four hours as needed for general discomfort, a 1-3 pain level (on a 1-10 pain scale, with 0=no pain and 10=worst pain), and tramadol HCl 50 mg by mouth every four hours as needed for moderate pain, a 4-6 pain level. Review of Resident 10's MAR for December 2023 showed tramadol HCl 50 mg was administered to Resident 10 on the following dates and times: - 12/5/23 at 0605 hours, for a pain level of 8 - 12/6/23 at 1557 hours, for a pain level of 7 - 12/7/23 at 0830 hours, for a pain level of 7 - 12/8/23 at 0133 hours, for a pain level of 8 - 12/9/23 at 0959 hours, for a pain level of 7 - 12/10/23 at 1023 hours, for a pain level of 7 - 12/13/23 at 0900 hours, for a pain level of 7 - 12/15/23 at 0955 hours, for a pain level of 9 - 12/22/12 at 1002 hours, for a pain level of 7 - 12/25/23 at 0500 hours, for a pain level of 7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 35 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0697 - 12/26/23 at 0134 hours, for a pain level of 8 Level of Harm - Minimal harm or potential for actual harm - 12/27/23 at 1418 hours, for a pain level of 7 - 12/27/23 at 0653 hours, for a pain level of 7 Residents Affected - Few - 12/27/23 at 2114 hours, for a pain level of 8 - 12/28/23 at 0951 hours, for a pain level of 8 - 12/29/23 at 0336 hours, for a pain level of 8 - 12/29/23 at 0956 hours, for a pain level of 9 Review of Resident 10's MAR for January 2024 showed tramadol HCl 50 mg was administered to Resident 10 on the following dates and times: - 1/1/24 at 0055 hours, for a pain level of 8 - 1/8/24 at 0455 hours, for a pain level of 7 - 1/11/24 at 0125 hours, for a pain level of 7 - 1/11/24 at 1010 hours, for a pain level of 8 - 1/15/24 at 1350 hours, for a pain level of 7 On 1/9/24 at 0950 hours, an interview with Resident 10 was conducted. Resident 10 stated she still experienced pain even after taking her tramadol in the past. Resident 10 further stated the licensed nurse did not offer her other medications to relieve her pain other than the tramadol 50 mg and repositioning to which did not help much. On 1/10/24 at 0949 hours, an interview as conducted with LVN 4. LVN 4 verified the physician should have been notified of Resident 10's pain level more than 7. On 1/12/24 at 1100 hours, an interview and concurrent record review with RN 5 was conducted. RN 5 verified an order of tramadol HCl 50 mg by mouth every four hours as needed was for moderate pain level of 4-6; and a pain level of more than 6 should have been addressed and the nursing staff should have notified the physician to provide comfort to the resident. 2. On 1/17/24 at 0930 hours, an observation and concurrent interview was conducted with Resident 23. Resident 23 was observed in bed. Resident 23 was asked about care and services received in the facility. Resident 23 stated on 1/14/23, he did not receive his scheduled pain medication at 0600 hours. Resident 23 stated he had constant pain and needed his medications around the clock. Resident 23 stated nobody tried to wake him up, nor offered the medication. Resident 23 was asked if he instructed the staff not to wake him for medications, and he stated no. Resident 23 stated he was made to wait until his 1200 hours dose to take the medication. Medical record review for Resident 23 was initiated on 1/17/24. Resident 23 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 36 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0697 facility on [DATE], and readmitted [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 23's History and Physical Form dated 10/6/23, showed Resident 23 had chronic pain syndrome. Residents Affected - Few Review of Resident 23's Order Summary Report showed an order dated 7/15/21, for Lyrica (a medication used to treat pain) 100 mg, give one capsule by mouth three times a day for nerve pain. Review of Resident 23's MAR for January 2024 showed Resident 23 was scheduled to have Lyrica at 0600, 1200, and 1800 hours daily. On 1/13/24 at 0600 hours, Resident 23's Lyrica medication was documented as not given because the resident was sleeping. Further review of the MAR showed Resident 23 next received the scheduled Lyrica at 1200 hours on 1/13/24. On 1/17/24 at 1015 hours, an interview was conducted with the DON. The DON was asked about Resident 23's missed medication. The DON stated she was aware of the situation. The DON stated Resident 23 was asleep and would sometimes yell at the staff if he was woken up, so the nurse did not give the 0600 hours dose of medication on 1/13/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 37 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure adequate 24-hour staffing was maintained to meet the residents' care needs. This failure had the potential to result in the residents not being provided with care consistent with professional standards of practice and care as outlined in their person-centered plans of care. * The facility failed to have adequate licensed nurses to administer the scheduled medications at 2100 hours on 1/9/24, for Residents 8, 9,and 10. * The facility failed to have adequate licensed nurses to provide the wound care to Residents 13, 14, and 15. * The facility failed to have adequate staff to ensure the care was provided timely to the residents on 1/9/24. These failures placed the residents at risk for adverse outcomes. Findings: Review of the facility's Facility Assessment, Part 3: Facility Resources Needed to Provide Competent Support and Care for out Resident Population Everyday and During Emergencies, showed the following nursing staffing plan: - Director of Nursing Services: One, Full-time - RN Supervisors: Three, daily (AM, PM, NOC) - Wound/treatment nurses: One to Two, daily - MDS Nurses: Two, Full-time - Restorative Nurse Assistants: Two to Three, Daily - RN/LVN Charge Nurses: Fourteen to Sixteen, Daily - CNAs: Thirty-Eight to Forty-Seven, Daily - LVN Case Manager: One, Full-time The document also showed the facility hires and schedules staff for an average census (135-165), including staff to cover vacation and sick time. The census average has been consistent at 125-165, and the highs and lows are brief periods. If the census peaks or there is a brief increase in admissions, PRN staff are scheduled or staff are scheduled overtime for additional coverage. Review of the facility's document resident census dated 1/8/24, showed a total of 166 residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 38 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. On 1/10/24 at 0810 hours, an interview was conducted with Residents 8, 9, and 10. The residents reported their concerns about not receiving their scheduled medications 2100 hours, due to insufficient staffing during the evening shift. On 1/10/24 at 0918 hours, and interview with LVN 4 was conducted. LVN 4 stated she was not sure if all residents were medicated on 1/9/24, because there were only two LVNs for the census of 168. LVN 4 further stated she got behind with passing the residents' medications due to being overwhelmed with 26-30 residents assigned to her today. On 1/10/24 at 1051 hours, an interview with LVN 7 was conducted. LVN 7 stated she reported for work on 1/9/24 at 2300 hours, where she was assigned to Nursing Station D. LVN 7 further stated LVN 1 left earlier than usual on 1/9/24, but no one took over LVN 1's assigned residents. LVN 7 stated the residents were complaining on the night of 1/9/24, about the medications were not given and call lights were not answered; and the resident were not happy when LVN 7 came to work at 2300 hours. LVN 7 verified this occurrence was not new, it happened almost every day and verbalized it was overwhelming even though she was doing her best. LVN 7 stated she cannot blame the residents if they screamed at the facility staff because they did not get the care that they need. On 1/11/24 at 1611 hours, an interview was conducted with the ADON. The ADON stated LVN 1 worked the day shift (0700-1500 hours) and evening shift (1500-2300 hours) on 1/9/24: however, LVN 1 left early at approximately 1900 hours, and did not finish the evening shift. The ADON stated she was unable to tell who replaced LVN 1 when she left. a. Medical record review for Resident 8 was initiated on 1/10/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 was cognitively intact. Review of Resident 8's Order Summary Report for January 2024 showed the physician's orders for the following medications: - aripiprazole 10 mg by mouth at bedtime related to unspecified psychosis, - melatonin 10 mg by mouth at bedtime for insomnia, - docusate sodium 100 mg by mouth two times a day for bowel management, - Eliquis 5 mg by mouth two times a day for DVT (deep vein thrombosis) prophylaxis, - gabapentin 300 mg by mouth every eight hours for neuropathy, - trazadone HCl 50 mg by mouth at bedtime for depression manifested by inability to sleep Review of Resident 8 ' s MAR for January 2023 showed no documented evidence Resident 8 was administered the above medications scheduled at 2100 hours on 1/9/24, as ordered by the physician. On 1/12/24 at 1045 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified there was no documented evidence Resident 8 was administered the aripiprazole 10 mg, melatonin 10 mg, trazadone HCl 50 mg, docusate sodium 100 mg, Eliquis 5 mg, gabapentin 300 mg on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 39 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Level of Harm - Minimal harm or potential for actual harm 1/9/24 at 2100 hours, as ordered by the physician. RN 5 further verified there was no documented evidence Resident 8's physician was notified on the medications not administered. b. Medical record review for Resident 9 was initiated on 1/10/24. Resident 9 was admitted to the facility on [DATE] Residents Affected - Some On 1/10/23 at 0810 hours, Resident 9 was observed to have ambulated to Nursing Station D. Resident 9 stated she did not get her scheduled medications on 1/9/24 at 2100 hours. Resident 9 further stated no one answered her call lights for the whole night last night because there was no nurse and CNA. Resident 9 further stated she activated her call light but did not get any response. Review of Resident 9's Order Summary Report for January 2024 showed the following orders: - dated 12/13/23, to administer atorvastatin calcium 80 mg by mouth at bedtime for hyperlipidemia. - dated 12/13/23, to administer topiramate 25 mg two times a day by mouth for migraines. - dated 12/13/23, to administer insulin lispro 100 unit/ml inject subcutaneously before meals and at bedtime as per sliding scale: if BS level 150-200 mg/dl = 2 units, 201-300 mg/dl = 4 units, 301- 400 mg/dl = 6 units, 401-500 mg/dl = 8units, and 501-600 mg/dl = 10 units, and call MD. - dated 12/13/23, to administer cefazolin sodium 1 gram intravenously every eight hours for osteomyelitis. - dated 12/14/23, to administer trazadone 50 mg by mouth at bedtime for depression manifested by inability to sleep. - dated 12/14/23, to administer buspirone HCl 5 mg two times a day by mouth for anxiety manifested by verbalization of feeling anxious. - dated 12/14/23, to administer pregabalin 75 mg two times a day by mouth for neurological pain. Review of Resident 9's MAR for January 2024 showed no documented evidence Resident 9 was administered the above oral medications scheduled at 2100 hours on 1/9/24, as ordered by the physician. Further review of Resident 9's IV MAR for January 2024 showed no documented evidence Resident 9 was administered the cefazolin sodium intravenously scheduled at 0600 hours on 1/5, 1/6, and 1/8/24, as ordered by the physician. On 1/12/24 at 1045 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified the above findings. RN 5 further verified there was no documented evidence Resident 9's physician was notified the medications were not administered. c. Medical record review for Resident 10 was initiated on 1/10/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 11/13/23, showed a diagnosis of tremors (an involuntary, quivering movement), neuralgia (is a sharp, shocking pain that follows the path of a nerve and is due to irritation or damage to the nerve), neuritis (an inflammatory or degenerative lesion of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 40 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Level of Harm - Minimal harm or potential for actual harm nerve marked especially by pain), diabetes mellitus (high blood sugar), muscle weakness, hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood) Review of Resident 10's Order Summary Report for January 2024 showed the physician's orders dated 11/10/23, to administer the following medications: Residents Affected - Some - atorvastatin calcium 20 mg by mouth at bedtime for lipidemia, - docusate sodium 250 mg by mouth at bedtime for bowel management, - melatonin 3 mg by mouth at bedtime for insomnia, - apixaban 2.5 mg by mouth two times a day for DVT prophylaxis, - gabapentin 300 mg by mouth every eight hours for neuropathy Review of Resident 10's MAR for January 2024 showed no documented evidence Resident 10 was administered the above medications scheduled at 2100 hours on 1/9/24, as ordered by the physician. On 1/12/24 at 1045 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified the above findings. RN 5 further verified there was no documented evidence Resident 10's physician was notified of the medications not administered on 1/9/24. Review of the facility's census from 1/8/24 to 1/10/24, showed the census ranged from 167 to 168 residents, with the average of 167. Review of the Nursing Staffing Assignment and Sign-in Sheets dated 1/9/24, showed six LVNs (including one LVN who went home early) were on duty from 1500-2300 hours, and two LVNs were on duty on 2300-0700 hours. Review of the Facility assessment dated [DATE], showed the facility's average census was 135 to 165 residents, with an average of 120-150 residents requiring assistance from one to two staff members for medical treatment like medication administration. The Facility Assessment Tool showed the total number of RN/LVN Charges Nurses needed daily was 14 to 16 daily. 2. Review of the facility document titled List of Residents Requiring Treatments dated 1/22/24, showed 36 residents, including Residents 13, 14, and 15 required wound care treatments. The wound care treatments were reviewed for Residents 13, 14, and 15 and showed the following: a. Medical record review for Resident 13 was initiated on 1/16/23. Resident 13 was admitted to the facility on [DATE], with a primary diagnosis of acute osteomyelitis (infection of the bone) of left ankle and foot. Review of Resident 13's Order Summary Report for January 2024 showed the physician's orders dated 12/26/23 (10 days after Resident 13's admission), for the following wound treatment: cleanse the left heel diabetic ulcer with normal saline, pat dry, apply medi-honey (an antibacterial gel used on wounds), and cover with a bordered gauze every day shift for wound healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 41 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 13's TAR dated December 2023 and January 2024 showed the above wound care order; however, there were no license nurses' initials showing the wound care was provided on 12/29, 12/31/23, 1/24, 1/5, 1/6, 1/10, and 1/12/24. On 1/17/24 at 1430 hours, a wound care observation of Resident 13's wound was conducted with LVN 5. After the wound care observation, LVN 5 was interviewed and verified the above findings. LVN 5 verified if there is no signature on the TAR, then the wound treatment was not done. LVN 5 verified Resident 13's treatments were not completed on the above listed dates. When asked about the missed wound treatments, LVN 5 stated there was difficulty with being the only treatment nurse on staff and he could have up to 80 residents with wound treatment orders if he was alone. LVN 5 stated he would prioritize if he was alone and would do all the treatments for pressure wounds, surgical wounds, diabetic wounds, and admissions; and the charge nurses were in charge of creams and GT dressings. b. Medical record review for Resident 14 was initiated on 1/17/23. Resident 14 was readmitted to the facility on [DATE]. Review of Resident 14's Order Summary Report for January 2024 showed the physician's orders dated 12/21/23, to perform wound treatment for the resident's Stage 4 pressure injury as follows: clean with normal saline, pat dry, apply med-honey, apply calcium alginate (a type of wound dressing), and cover with an absorbent bordered gauze every day shift. Review of Resident 14's TAR for January 2024 showed no documented evidence the above wound treatment was provided to the resident on 1/1, 1/6, and 1/11/24. On 1/18/24 at 0729 hours, an interview was conducted with Resident 14. Resident 14 was observed in bed with a low-air loss mattress. Resident 14 stated he had a bed sore on his back side and the wound was treated every day. Resident 14 stated he had missed treatments about once a week. c. Medical record review for Resident 15 was initiated on 1/17/23. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's Order Summary Report dated 1/17/24, showed the physician's orders for the following wound treatments: - For the right buttock Stage 4 pressure injury: cleanse with normal saline, pat dry, apply medi-honey and calcium Alginate and cover with dry dressing every day shift, ordered on 4/5/23. - For the left ischium healed Stage 4 pressure injury: cleanse with normal saline, pat dry, apply barrier cream, leave open to air, every day shift for maintenance, ordered on 12/5/23. - For the left lower extremity scattered peripheral vascular disease (PVD, a circulation disorder caused by narrowed blood vessels in the limbs) ulcers: cleanse with normal saline, pat dry, apply xeroform and collagen powder, cover with an abdominal pad and wrap with a gauze every day shift, every other day, ordered 8/17/23. - For the sacral coccyx MASD: apply barrier cream to clean dry skin and leave open to air every day shift for treatment, ordered on 10/2/23 Review of Resident 15's TAR for December 2023 and January 2024 showed no documented evidence the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 42 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some above wound treatments were provided on 12/2, 12/15, 12/16, 12/17, 12/18, and 12/20/23, 1/1, 1/2, 1/4, 1/5, 1/6, 1/11, and 1/12/24. On 1/17/24 at 1430 hours, a wound care observation of Resident 15's wound was conducted with LVN 5. After the wound care observation, LVN 5 was interviewed regarding the above findings. LVN 5 acknowledged and verified the above findings. LVN 5 verified if there was no signature present on the TAR, then the wound treatment was not done. When asked about the missed wound treatments, LVN 5 acknowledged there was difficulty with being the only treatment nurse on staff and he could have up to 80 residents with wound treatment orders if he was alone. LVN 5 stated he would prioritize if he was alone and would do all the treatments for pressure wounds, surgical wounds, diabetic wounds, and admissions; and the charge nurses were in charge of creams and GT dressings. Review of the facility staffing assignments showed the following number of treatment nurses were on duty for the above missed treatment days: - 12/15/23 - one - 12/16/23 - none - 12/17/23 - one - 12/18/23 - one - 12/20/23 - one - 12/29/23 - one - 12/31/23 - none - 1/1/24 - none - 1/2/24 - one - 1/4/24 - one - 1/5/24 - one - 1/6/24 - one - 1/10/24 - one - 1/11/24 - one - 1/12/24 - one The facility failed to ensure adequate nursing staff to meet the residents' care needs. On 1/23/24 at 1130 hours, the Administrator and DON were informed of and acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 43 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0725 Cross references to F684 and F686. Level of Harm - Minimal harm or potential for actual harm 3.a. On 1/9/24 at 0919 hours, an interview was conducted with Resident 11. Resident 11 stated the facility seemed understaffed with CNAs and they were given too many residents to take care of. Resident 11 stated every time she turned on her call light, she would have to also call the facility's main telephone line to have someone call for a CNA to assist her. Residents Affected - Some b. On 1/9/24 at 0923 hours, an interview was conducted with Resident 12. Resident 12 stated she could not walk and needed full assistance from the facility staff but could turn in bed by herself. Resident 12 stated she was able to put herself on and off the bedpan but needed assistance to clean herself. Resident 12 stated she pushed the call light that morning at 3:30 AM and did not get assistance to be cleaned until 7:30 AM. Resident 12 stated she used the clock on her phone to know the time she called. Resident 12 stated she felt disgusted having to wait that long to be assisted. Resident 12 stated the facility seemed short staffed. c. On 1/12/24 at 0923 hours, another follow-up interview was conducted with Resident 2. Resident 2 was asked how long he waited for assistance after using the call light. Resident 2 stated he had waited up to 7 hours during the night (2300 to 0700 hours) shift. Resident 2 stated there were times he had to sit in his stool, and it made him feel uncomfortable and caused pain. Cross reference to F558. The facility failed to ensure adequate staff to meet the residents' care needs. Review of the facility's document resident census dated 1/8 and 1/9/24, showed a total of 166 and 168 residents, respectively. On 1/10/24 at 1051 hours, an interview was conducted with RN 2 regarding her shift on 1/9/24. RN 2 stated the facility was extremely understaffed and two LVNs had called off. RN 2 stated there were two LVNs and one RN on that night (not counting RN 2). RN 2 stated they were overwhelmed, and it was overly stressful and impossible to come up with a workable assignment. RN 2 stated the assigned workload was 83 patients to each LVN and one CNA had abandoned her shift that night. RN 2 stated RN 3 did not come into work until 1:15 AM. On 1/10/24 at 1116 hours, an interview was conducted with RN 3 regarding his shift on 1/9/24. RN 3 stated he got to the facility around 12 o'clock that night and was assigned to more than 50 residents. RN 3 stated they were extremely understaffed that night, and there were two LVNs and two RNs, but he was working on the medication cart. RN 3 stated it was so many residents and could not recall who he was able to get to that night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 44 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration, reconciliation, and disposition of all drugs to meet the needs of the residents. * The facility failed to ensure the physical inventory of controlled medications was conducted during shift change as per the facility's P&P, for one of the six medication carts (Medication Cart A). * The facility failed to ensure administration of the medications for Resident 9 and Resident D were accurately documented to ensure accurate reconciliation and prevent medication errors. These failures posed the risk for diversion and medication administration errors. Findings: 1. Review of the facility's P&P titled Controlled Substances Log Blue Book Process (undated) showed for the shift-to-shift count, the controlled medication reconciliation will occur between incoming and outgoing nursing at shift change for the physical inventory of controlled medications. The license nurses will sign on the Shift Count page. On 1/12/2024 at 1036 hours, an interview and concurrent facility document review with LVN 1 was conducted. LVN 1 was asked to explain the facility's P&P for the accurate accounting and inventory of controlled medications. LVN 1 stated at the end of every shift, the oncoming and outgoing licensed nurses accounted for all resident controlled medications in the facility's medication cart. A physical count of all resident-controlled medications was conducted and verified with the narcotic count sheet for each controlled medication. At the conclusion of the count, if both licensed nurses confirmed the controlled medication count was accurate, the licensed nurses would then sign the facility's Shift Count form. LVN 1 stated any discrepancies would immediately be reported to the DON. LVN 1 verified if signature was missing in the Shift Count form, the physical count of controlled medications was not performed. Review of the facility's Shift Count form showed the controlled medications count for Medication Cart 1 were missing signatures on 12/26/23 for the 11-7 shift, 1/2/24 for 1500-2300 shift and 2300-0700 shift, 1/8/24 for the 2300-0700 shift, and 1/12/24 for the 2300-0700 shift. LVN 1 verified she was assigned to Medication Cart 1 on 1/12 at 0700-1500 hours shift. LVN 1 further verified the Shift Count form was missing signatures on the above dates. LVN 1 further stated the licensed staff was required to conduct a physical count of all the controlled medications in Medication Cart A with another licensed nurse between shifts, then sign the form to conform accuracy of the narcotics in Medication Cart A. On 1/12/24 at 1053 hours, an interview and concurrent facility record review with RN 5 was conducted. RN 5 verified the above findings. 2. Review of the facility's P&P titled Preparation and General Guidelines Medication Administration dated 10/2019 showed during the administration, the medications are administered in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 45 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - Few written orders of the attending physician, medications are administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber routine medications are administered according to the established medication administration schedule for the facility. During documentation, the individual who administers the medication dose records the administration on the resident's MAR after the medication pass is complete. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary does were administered and documented. If a dose of regularly scheduled medication is withheld, refuse, not available, or given at a time other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is (initialed and circled) An explanatory note is entered on the reverse side of the record provided for PRN documentation. If (two consecutive doses) of a vital medication are withheld, refuse, or not available the physician is notified. a. Medical record review for Resident 9 was initiated on 1/10/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Order Summary Report for January 2024 showed the following physician's orders: - dated 12/13/23, to administer atorvastatin calcium 80 mg by mouth at bedtime for hyperlipidemia. - dated 12/13/23, to administer topiramate 25 mg two times a day by mouth for migraines. - dated 12/13/23, to administer insulin lispro 100 unit/ml inject subcutaneously before meals and at bedtime as per sliding scale: if BS level 150-200 mg/dl = 2 units, 201-300 mg/dl = 4 units, 301- 400 mg/dl = 6 units, 401-500 mg/dl = 8units, and 501-600 mg/dl = 10 units, and call MD. - dated 12/13/23, to administer cefazolin sodium 1 gram intravenously every eight hours for osteomyelitis. - dated 12/14/23, to administer trazadone 50 mg by mouth at bedtime for depression manifested by inability to sleep. - dated 12/14/23, to administer buspirone HCl 5 mg two times a day by mouth for anxiety manifested by verbalization of feeling anxious. - dated 12/14/23, to administer pregabalin 75 mg two times a day by mouth for neurological pain. On 1/11/24 at 2110 hours, a medication administration observation was conducted for Resident 9. During the medication administration, LVN 7 was observed administering trazadone and two units of insulin lispro after obtaining blood glucose level of 184 mg/dl. LVN 7 verified Resident 9 only had two medications due at 2100 hours. However, review of Resident 9's MAR for January 2024 showed Resident 9's following medications were administered on 1/11/24 at 2100 hours, not only two medications as per the above observation and LVN 7's interview: - atorvastatin calcium 80 mg by mouth at bedtime for hyperlipidemia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 46 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - trazadone HCl 50 mg by mouth at bedtime for depression Level of Harm - Minimal harm or potential for actual harm - buspirone HCl 5 mg for anxiety - pregabalin75 mg for neurological pain Residents Affected - Few - topiramate 25 mg for migraines - insulin lispro injection as per sliding scale Review of Resident's 9 Medication Admin Audit Report showed the actual times when the LVN administered the resident's medications on 1/11/24, as follows: - atorvastatin calcium 80 mg by mouth at bedtime for hyperlipidemia was administered at 2038 hours. - trazadone HCl 50 mg by mouth at bedtime for depression was administered at 2116 hours. - buspirone HCl 5 mg for anxiety was administered at 2038 hours. - pregabalin75 mg for neuro pain was administered at 2038 hours. - topiramate 25 mg for migraines was administered at 2038 hours. - insulin lispro injection per sliding scale was administered at 2116 hours. b. Medical record review for Resident D was initiated on 1/13/24. Resident D was admitted to the facility on [DATE]. On 1/11/24 at 2141 hours, a medication administration observation was conducted for Resident D with LVN 7. LVN 7 was observed administering the following medications: - melatonin 5 mg one tablet - senna 8.6 mg two tablets - mag oxide 400 mg one tablet - dilaudid 2 mg one tablet Review of Resident D's Order Summary Report for January 2024 showed the following orders: - dated 11/5/23, to administer hydromorphone HCl 2 mg by mouth every four hours for moderate pain - dated 12/13/23, to administer asper cream lidocaine external cream 4% apply to painful areas topically every 24 hours for pain management apply for 12 hours then remove - dated 12/13/23, to administer gabapentin 900 mg by mouth every eight hours for neurological pain - dated 12/13/23, to administer melatonin 5 mg by mouth at bedtime for insomnia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 47 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - dated 12/13/23, to administer senokot extra strength two tablets by mouth at bedtime for constipation Level of Harm - Minimal harm or potential for actual harm - dated 12/14/23, cyclobenzaprine HCl 10 mg one tablet every eight hours by mouth for muscle spasm Residents Affected - Few Review of Resident D's MAR for January 2024 showed Resident D was administered the following medications on 1/11/24: - melatonin 5 mg one tablet by mouth at bedtime for maintain cardiac rhythm at 2100 hours. - senokot extra strength 17.2 mg two tablets by mouth at bedtime for bowel management at 2100 hours. - cyclobenzaprine HCl one tablet by mouth every eight hours for muscle spasm at 2100 hours. - gabapentin 900 mg by mouth every eight hours for neuro pain at 2200 hours. - hydromorphone HCl 2 mg one tablet by mouth every four hours as needed for moderate pain at 2143 hours. - asper cream lidocaine external cream 4% apply to painful areas topically every 24 hours for pain management at 2126 hours. Review of Resident D's Medication Admin Audit Report from 1/1/24 to 1/16/24, showed the actual times when LVN 7 administered the resident's medications on 1/11/24, as follows: - Asper cream lidocaine external cream 4% apply to painful areas topically every 24 hours for pain management apply for 12 hours then remove was administered at 2126 hours. - senokot extra strength 17.2 mg 2 tablets by mouth at bedtime for constipation hold for loose stools was administered at 2142 hours. - melatonin 5 mg 1 tablet by mouth at bedtime to maintain cardiac rhythm was administered at 2142 hours. - hydromorphone HCl 2 mg by mouth every 4 hours as needed for moderate pain was administered at 2144 hours. - gabapentin 900 mg by mouth every 8 hours for neuro pain was administered at 2126 hours. - cyclobenzaprine HCl 10 mg one tablet by mouth every eight hours for muscle spasm was administered at 2126 hours. On 1/11/24 at 2203 hours, an interview was conducted with LVN 7. LVN 7 stated she had administered Resident 9's atorvastatin, buspar, lyrica, and topamax prior to the medication administration observation at 2110 hours. LVN 7 further stated she had administered Resident D's gabapentin prior to the above medication administration observation at 2120 hours. LVN 7 stated she sometimes gave the medications and did not sign and would sign it as given later. LVN 7 stated she gave the residents' medications when they needed it, and every resident was different. Sometimes she signed without giving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 48 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the medications, then gave the medications when the residents were ready. LVN 7 further stated this was her practice. LVN 7 stated she did not notify the MD of these changes. On 1/12/24 at 1042 hours, an interview with RN 5 was conducted. RN 5 stated the policy of the facility for medication administration was to record the administration of the medication on the resident's MAR right after the medication pass. RN 5 stated, it is not the policy of the facility to give a medication now then sign later, or sign now then give the medication later. Event ID: Facility ID: 555765 If continuation sheet Page 49 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 29 sampled residents' (Resident 17) medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. * Resident 17 had a physician's order for the use of Seroquel (antipsychotic medication) for hallucinations; however, there was no monitoring of the behaviors and side effects in place. This failure had the potential for Resident 17 to receive the unnecessary psychotropic medication and/or the physician to not know the effects of the medication. Findings: Review of the facility's P&P titled Psychotropic Drug Use revised 8/2017 showed the licensed nurse shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse effects prior to verification of admission orders with the attending physician. The SSD and/or nursing designee will be responsible for initiating the resident's individualized, person-centered psychosocial plan of care, based on their comprehensive initial admission assessment. Monitoring for adverse consequences and effectiveness of the medications are in place. Medical record review for Resident 17 was initiated on 1/12/24. Resident 17 was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident 17's Order Summary Report showed an order dated 1/15/24, for Seroquel oral tablet 50 mg, give one tablet by mouth at bedtime for hallucinations. Further review of the medical record failed to show any monitoring for the episodes of hallucinations or side effects of the medication. On 1/18/24 at 0744 hours, an interview and concurrent medical record review was conducted with LVN 13. LVN 13 reviewed Resident 17's medical record and verified Resident 17 had a physician's order for Seroquel; however, there was no behavior or side effects monitoring in place. Cross reference to F657. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 50 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of 29 sampled residents (Residents 8 and 9) were free from the significant medication errors. The facility failed to administer Residents 8 and 9 their scheduled medications. This failure put the Residents 8 and 9 at risk for medical complications. Residents Affected - Few Findings: Review of the facility's P&P titled Preparation and General Guidelines Medication Administration-General Guidelines dated October 2016 showed the following: - The medications are administered in accordance with written orders of the attending physician. - The medications are administered are administered within (60 minutes) of scheduled time, except before and after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule of the facility. - If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is (initialed in circled). An explanatory note is entered on the reverse side of the record provided for PRN documentation. If (two consecutive doses) of a vital medication are withheld, refused, or not available the physician is notified. 1. Medical record review for Resident 8 was initiated on 1/10/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 12/4/23, showed a diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), functional quadriplegia (complete immobility due to severe disability), polyneuropathy (when multiple peripheral nerves become damaged), and anxiety(intense, excessive, and persistent worry and fear about everyday situations). Review of Resident 8's Order Summary Report showed the following physician's orders: - dated 11/30/23, to administer aripiprazole 10 mg by mouth at bedtime related to unspecified psychosis, - dated 11/30/23, to administer melatonin 10 mg by mouth at bedtime for insomnia, - dated 11/30/23, to administer docusate sodium 100 mg by mouth two times a day for bowel management, - dated 11/30/23, to administer Eliquis 5 mg by mouth two times a day for DVT (deep vein thrombosis-a blood clot in a deep vein, usually in the legs) prophylaxis, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 51 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 - dated 11/30/23, to administer gabapentin 300 mg by mouth every eight hours for neuropathy (weakness, numbness, and pain in the hands and feet), - dated 12/1/23, to administer trazadone HCl 50 mg by mouth at bedtime for depression manifested by inability to sleep Residents Affected - Few Review of Resident 8's MAR for January 2023 showed no documented evidence Resident 8 was administered the above medications on 1/9/24 at 2100 hours, as ordered by the physician: On 1/12/24 at 1045 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified the above findings. RN 5 further verified there was no documented evidence Resident 8's physician was notified on medications not administered. 2. Medical record review for Resident 9 was initiated on 1/10/24. Resident 9 was admitted to the facility on [DATE] Review of Resident 9's MDS showed a BIMS score of 15 (score of 13-15 signifies cognitively intact). During an observation on 1/10/23 at 0810 hours, Resident 9 came to Nursing Station 1B. Resident 9 stated she did not get her scheduled medications last night at 2100 hours. Review of Resident 9's Order Summary Report for January 2024 showed the following physician's orders: - dated 12/13/23 to administer atorvastatin calcium 80 mg by mouth at bedtime for hyperlipidemia. - dated 12/13/23 topiramate 25 mg two times a day by mouth for migraines. - dated 12/13/23 to administer insulin lispro 100 unit/ml inject subcutaneously as per sliding scale: if BS level 150-200 mg/dl = 2 units, 201-300 mg/dl = 4units, 301-400 mg/dl = 6units, 401-500 mg/dl = 8units, 501-600 mg/dl =10 units, call MD. - 12/13/23, to administer cefazolin sodium 1 gram intravenously every eight hours for osteomyelitis. - dated 12/14/23,to administer trazadone 50 mg by mouth at bedtime for depression manifested by inability to sleep. - dated 12/14/23,to administer buspirone HCl 5 mg two times a day by mouth for anxiety manifested by verbalization of feeling anxious. - dated 12/14/23,to administer pregabalin 75 mg two times a day by mouth for neurological pain. Review of Resident 9's MAR for January 2023 showed no documented evidence the above medications were administered to Resident 9 on 1/9/24 at 2100 hours. The MAR also showed insulin lispro was not administered on 1/13/24 at 0630, 1630, and 2000 hours. Further review of Resident 9's IV MAR for January 2023 showed no documented evidence Resident 9 was administered the cefazolin sodium intravenously on 1/5, 1/6, 1/8 at 0600 hours, as ordered by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 52 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 physician. Level of Harm - Minimal harm or potential for actual harm On 1/12/24 at 1045 hours, an interview and concurrent medical record review was conducted with RN 5. RN 5 verified the above findings. Residents Affected - Few RN 5 further verified insulin lispro was not administered per sliding scale on 1/9/24 at 2000 hours, and 1/13/24 at 0630, 1630, and 2000 hours; and cefazolin sodium 1 gram on 1/5, 1/6, 1/8, and 1/9/24 at 0600 hours, as ordered by the physician. Cross reference to F684. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 53 of 54 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 555765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the garbage was stored in a sanitary manner. This posed a threat of pest contamination. Residents Affected - Some According to the USDA Food Code 2017, 5-501.113, Covering Receptacles, receptacles and waste handling units for refuse .shall be kept covered (B) with tight-fitting lids or doors if kept outside the food establishment. On 1/17/24 at 1424 hours, an observation and concurrent interview with Maintenance Assistant was conducted. Two of two dumpsters were observed overflowing with garbage restricting the lid from closing. The Maintenance Assistant confirmed dumpsters should be closed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 54 of 54