Inspection visit

Health inspectionFebruary 8, 2024

THE HILLS POST ACUTECMS #55576537 citations on this visit

37 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 37 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 four of 33 final sampled residents (Residents 49, 61, 107, and 122) were informed in advance regarding their proposed treatments. Residents Affected - Few * The facility failed to ensure the informed consent was obtained from Resident 107 before administering lorazepam (antianxiety medication) to Resident 107. * The facility failed to ensure the informed consent was obtained from Resident 49 before administering sertraline (antidepressant medication) to Resident 49. * The facility failed to ensure Resident 122's informed consent for mirtazapine (antidepressant medication) was obtained. * The facility failed to ensure Resident 61's informed consent for nortriptyline (antidepressant medication) was obtained prior to medication administration. These failures had the potential to compromise the rights of the residents or their responsible party (person designated to make decisions on behalf of the resident) to be fully informed regarding the medications and the potential side effects. Findings: Review of the facility's P&P titled Care and Treatment revised 5/2019 showed under the Informed Consent section, it is the policy of the facility that resident rights are not violated and a copy of these rights and pertinent polices are made available to the resident and to any representative of the resident. Among these rights under this section are: - The right to receive in advance all information that is material to a decision to accept or refuse treatment; - To consent to or refuse any treatment or procedure or participation in experimental research; and - To participate in care planning. Review of the facility's P&P titled Care and Treatment revised 8/2017 showed under the Psychotropic Drug use section, upon initial comprehensive assessment, the Social Services designee shall review new admission for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or the physician's orders for psychotropic medications. These residents will be referred to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 99 Event ID: 555765 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 02/08/2024 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 0552 Level of Harm - Minimal harm or potential for actual harm facility's Psychotropic Drug Review Committee and/or psychiatrist to ensure informed consent was obtained prior to medication use. 1. Medical record review for Resident 107 was initiated on 2/4/24. Resident 107 was readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 107's MDS dated [DATE], showed Resident 107 was cognitively intact. Review of Resident 107's Order Summary Report showed a physician's order dated 9/26/23, to administer lorazepam 0.5 mg one tablet by mouth three times a day for anxiety. Review of Resident 107's MAR for January and February 2024 showed Resident 107 received the lorazepam medication from 1/1/24 to 2/4/24 at 0900, 1300, and 1700 hours. Further review of Resident 107's medical record did not show documented evidence an informed consent for the lorazepam medication was obtained from Resident 107. 2. Medical record review for Resident 49 was initiated on 2/4/24. Resident 49 was readmitted to the facility on [DATE]. Review of Resident 49's MDS dated [DATE], showed Resident 49 was cognitively intact. Review of Resident 49's Order Summary Report showed a physician's order dated 10/22/23, to administer sertraline 100 mg one tablet by mouth at bedtime for depression. Review of Resident 49's MAR for January and February 2024 showed Resident 49 received the sertraline medication from 1/1 to 2/1/24, and 2/3 to 2/7/24 at 2100 hours. Further review of Resident 49's medical record did not show documented evidence an informed consent for the sertraline medication was obtained from Resident 49. On 2/7/24 at 1310 hours, an interview and concurrent medical record review for Residents 49 and 107 was conducted with the DON. The DON verified the above findings. The DON verified there were no informed consent forms completed for Residents 49 and 107. 3. Resident 122 was admitted to the facility on [DATE], with a diagnosis of dementia. Review of Resident 122's Order Summary Report showed an order dated 4/47/23, for mirtazapine tablet 7.5 mg to be given by mouth at bedtime for depression manifested by poor appetite. Review of Resident 122's H&P examination dated 4/28/23, showed Resident 122 had impaired judgement. Review of Resident 122's MAR for January and February 2024 showed Resident 122 received mirtazapine every night. Review of Resident 122's medical record failed to show of an informed consent for mirtazapine. On 2/8/24 at 1902 hours, a concurrent interview and record review was conducted with the DSD. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 2 of 99 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 02/08/2024 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked about psychotropic medications, the DSD stated an informed consent should be signed by the resident or representative. Upon review of Resident 122's medical record, the DSD verified there was no informed consent for mirtazapine. 4. Medical record review for Resident 61 was conducted on 2/4/24. Resident 61 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 61's Order Summary Report dated 2/8/24, showed a physician's order dated 1/12/24, for nortriptyline HCL Oral capsule 10 mg one capsule by mouth one time a day for depression m/b sad facial expression. Review of Resident 61's MAR for 1/2024, showed Resident 61 received nortriptyline HCL 10 mg one capsule by mouth daily from 1/13-1/31/24. Review of Resident 61's MAR for 2/2024, showed Resident 61 received nortriptyline HCL 10 mg one capsule by mouth daily from 2/1-2/8/24. Review of Resident 61's medical record failed to show documented evidence an informed consent for nortriptyline HCL was obtained prior to the administration of the medication. On 2/8/24 at 0951 hours, an interview and concurrent medical record review for Resident 61 was conducted with LVN 12. LVN 12 verified Resident 61 had an order for the nortriptyline HCL medication. When asked regarding the facility's process before a resident was started on psychotropic medication, LVN 12 stated she needed to notify the physician for the informed consent. When asked if Resident 61 should have been administered the nortriptyline HCL without an informed consent, LVN 12 stated no. LVN 12 verified Resident 61 did not have an informed consent for the nortriptyline HCL. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 3 of 99 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 02/08/2024 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 0553 Level of Harm - Potential for minimal harm Residents Affected - Some Allow resident to participate in the development and implementation of his or her person-centered plan of care. **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 ensure one of 33 final sampled residents (Resident 812) was provided with the opportunity to participate in care plan meeting. * The facility failed to ensure Resident 812 was provided with the opportunity to be informed of the plan of care. This failure had the potential for Resident 812 to not be able to choose the treatment options and make the decisions in the care planning. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated November 2016 showed within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social services; and f) PASARR recommendations; if applicable. The facility team will provide a written summary of the baseline care plan to the resident and their representative that includes the initial goals of the resident, a summary of medications and dietary instructions, and any services and treatments to be administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 4 of 99 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 02/08/2024 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 0553 Level of Harm - Potential for minimal harm On 2/4/24 at 0921 hours, during the initial tour of the facility, Resident 812 was observed lying in bed and stated there had not been any care plan meeting to discuss her care. Resident 812 stated she would like to know about her treatment. Medical record review for Resident 812 was initiated on 2/5/24. Resident 812 was admitted [DATE]. Residents Affected - Some Further review of Resident 812's medical record failed to show an IDT meeting for the baseline care plan was conducted for Resident 812 On 2/6/24 at 1400 hours, a concurrent interview and medical record review with the MDS Coordinator was conducted. The MDS Coordinator stated all staff were responsible for developing the care plans for the residents. The MDS Coordinator further stated the SSD would send the invitation to the resident and/or resident representative to attend the care plan meeting. The MDS Coordinator reviewed Resident 812's medical record and verified the findings. On 2/7/24 at 0925 hours, a concurrent interview and medical record review with the DON was conducted. The DON stated the baseline care plan should be done within 48 hours. The residents were usually informed of their plans of care within two to three days after admission and usually done at the bedside. The baseline care plan should be documented in the IDT notes. Review of Resident 812's medical record with the DON failed to show any documentation regarding the discussion of the plan of care with Resident 812. The DON was informed and acknowledged the above findings. On 2/7/24 at 1344 hours, an interview with the SSD was conducted. The SSD stated baseline care plan meeting had not been conducted for Resident 812. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 5 of 99 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 02/08/2024 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 ensure one of 33 final sampled residents (Resident 24) was assessed to safely self-administer the medications prior to performing the self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being and could administer the medications inaccurately. Residents Affected - Few Findings: Review of the facility's P&P titled Care and Treatment, Self Administration of Medications revised 5/2019 showed the purpose of the policy is to determine the ability of alert residents to participate in self-administration of medication and maintain the safety and accuracy of medication administration. The policy also showed if a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status with the LN-Self Administration of Medication UDA. During the initial tour of the facility on 2/4/24 at 1154 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24 was observed with the Dry Eye Relief (used to provide temporary relief of burning and irritation due to dryness of the eye) eye drop at bedside. When asked, Resident 24 stated she instilled the eye drop to both of her eyes at night and the licensed nurses were aware that she had the eye drop at the bedside. On 2/6/24 at 1630 hours, Resident 24 was observed with the Dry Eye Relief eye drop at the bedside. Medical record review for Resident 24 was initiated on 2/4/24. Resident 24 was readmitted to the facility on [DATE]. Review of Resident 24's H&P examination dated 10/3/23, showed Resident 24 had the capacity to make decisions for herself. Review of Resident 24's LN-Self Administration of Medications-Initial Evaluation dated 6/8/23, showed Resident 24 was not approved to self-administer because she was unable to exhibit the ability to understand medication administration. Further review of the medical record showed there was no physician's order for the self-administration of the Dry Eye Relief eye drop and for the medication to be stored at the resident's bedside. In addition, there was no care plan problem initiated or developed to address the resident's self-administration of the medication. On 2/4/24 at 1218 hours, an observation and concurrent interview was conducted with LVN 13. LVN 13 verified Resident 24 had the Dry Eye Relief eye drop at the bedside. LVN 13 stated it was the first time she observed the eye drop at the bedside. On 2/7/24 at 0818 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified Resident 24 did not have the physician's order for self-administration of the Dry Eye Relief eye drop and a care plan problem addressing the resident's self-administration of the eye drop medication. RN 1 verified Resident 24's LN-Self Administration of Medications- Initial Evaluation dated 6/8/23, showed she was not approved to self-administer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 6 of 99 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 02/08/2024 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 0554 Level of Harm - Minimal harm or potential for actual harm On 2/7/24 at 0828 hours, an interview was conducted with the DON. The DON stated the residents who wanted to self-administer medications should be assessed to ensure they were capable to safely self-administer the medications and a care plan should be developed to address the self-administration of the medications. In addition, the DON stated the physician should be notified to obtain the orders for the self-administration of the medication and to store the medication at the bedside. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 7 of 99 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 02/08/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of facility's P&P titled Catheter Care, Indwelling reviewed December 2019 showed to cover the drainage bag with a privacy bag. Residents Affected - Few a. Medical record review for Resident 1 was initiated on 2/5/24. Resident 1 was admitted to facility on 7/29/22, and readmitted on [DATE]. Review of the H&P examination dated on 1/13/24, showed Resident 1 was able to make needs known and his own decision. Review of Resident 1's Order Summary Report for February 2024 showed a physician's order dated 1/6/24, for an indwelling urinary catheter for diagnosis of neurogenic bladder. On 2/4/24 at 0938 hours, during the initial tour, Resident 1's indwelling urinary catheter drainage bag was observed hanging to the right side of the bed without a dignity bag. On 2/4/24 at 0940 hours, a concurrent interview was conducted with CNA 7. CNA 7 verified the above findings and stated there should be a dignity bag for the urinary drainge bag. On 2/4/24 at 1038 hours, an interview with LVN 9 was conducted. LVN 9 stated the residents with indwelling urinary catheters should be provided with a dignity bag. On 2/7/24 at 0911 hours, an interview with the DON was conducted. The DON stated the urinary drainage bag should be in a dignity bag. The DON was informed and acknowledged the above findings. b. Medical record review for Resident 131 was initiated on 2/5/24. Resident 1 was admitted to facility on 4/21/23 and was readmitted on [DATE]. Review of Resident 131's Order Summary Report for February 2024 showed a physician's order dated 1/23/24, for a lower abdomen suprapubic urinary catheter for diagnosis of neurogenic dysfunction of urinary bladder. On 2/4/24 at 0930 hours, during the initial tour, Resident 131's indwelling urinary catheter drainage bag was observed hanging to the right side of the bed without a dignity bag. On 2/4/24 at 0938 hours, an interview and concurrent interview was conducted with CNA 7. CNA 7 verified the above findings and stated there should be a dignity bag for the indwelling urinary catheter urine bag. On 2/4/24 at 0943 hours, an interview with LVN 9 was conducted. LVN 9 stated the residents with indwelling urinary catheters should be provided with a dignity bag. On 2/7/24 at 0923 hours, an interview with the DON was conducted. The DON stated the urinary drainage bag should be in a dignity bag. The DON was informed and acknowledged the above findings. c. Medical record review for Resident 133 was initiated on 2/5/24. Resident 133 was admitted to facility on 9/22/23, 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 8 of 99 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 02/08/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm Review of Resident 133's Order Summary Report for January 2024 showed a physician's order dated 12/21/23, for an indwelling urinary catheter. On 2/4/24 at 0941 hours, during the initial tour, Resident 133's indwelling urinary catheter drainage bag was observed hanging to the left side of the bed without a dignity bag. Residents Affected - Few On 2/4/24 at 1041 hours, a concurrent observation and interview with LVN 9 was conducted. LVN 9 acknowledged Resident 133's drainage bag did not have a dignity bag. LVN 9 stated the residents with indwelling urinary catheters should be provided with a dignity bag. On 2/7/24 at 1030 hours, an interview with the DON was conducted. The DON stated the urinary drainage bag should be in a dignity bag. The DON was informed and acknowledged the above findings. Based on observation, interview, and facility P&P review, the facility failed to provide privacy to six of 33 final sampled residents (Residents 1, 12, 61, 128, 131, and 133) and one nonsampled resident (Resident 963). * The facility failed to provide privacy by closing the curtains while applying the topical medication patch to Resident 12's right hip. * The facility failed to provide privacy by closing the curtains while administering the medications via GT for Resident 61. * The facility failed to provide privacy when providing wound care to Resident 128. * The facility failed to ensure Residents 1, 131, and 133 were provided a dignity bag for their indwelling urinary catheter drainage bag as per the facility's P&P. * The facility failed to ensure Resident 963's laboratory results were safeguarded to protect the resident's confidential health information. These failures had the potential for the residents to be exposed to the public view and negatively impact the residents' psychosocial wellbeing, right to privacy and preservation of dignity. Findings: Review of the facility's P&P titled Nursing Administration dated 11/21 showed the residents shall be examined and treated in a manner that maintains their privacy. 1. Medical Record review for Resident 12 was initiated on 2/4/24. On 2/4/24 at 0844 hours, during the medication administration obsservation for Resident 12, LVN 17 did not close the curtains while applying a lidocaine patch to Resident 12's right hip. LVN 17 acknowledged immediately and stated she forgot to close the curtains while applying the topical medication. 2. Medical Record review for Resident 61 was initiated on 2/4/24. On 2/4/24 at 0812 hours, the medication administration observation was conducted. During the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 9 of 99 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 02/08/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm medication administration via GT, LVN 8 closed Resident 61's door and curtains facing the door, but did not close the curtains facing the window. An observation and concurrent verification with LVN 8 was conducted. LVN 8 verified there were several missing blinds by the window and some blinds were left open. When asked, LVN 8 stated he should have closed the curtains closest to the window, and stated he was unsure how long the blinds had been missing. Residents Affected - Few 3. On 2/4/24 at 1005 hours, LVN 1 was observed providing wound care to Resident 128's sacral ulcer. LVN 1 verified the physician's order, performed hand-hygiene, but failed to provide privacy by leaving the window blind opened while providing the wound care. Resident 128's bed was positioned by the window. On 2/4/24 at 1020 hours, an interview with LVN 1 who was the treatment nurse was conducted. LVN 1 stated prior to providing wound care, she would need to verify the physician's order, perform hand-hygiene, and provide privacy. When asked if the window blinds should be closed, LVN 1 verbalized it should be closed for privacy. On 2/6/24 at 1410 hours, an interview was conducted with supervisor RN 1 confirmed all residents' care should encompassed the right to privacy. 5. Review of the facility's undated P&P titled Resident Rights, Release of Information showed it is the policy of this facility that the facility maintains the confidentiality of each resident's personal and clinical records. Resident records, whether medical, financial, or social in nature, are safeguarded to protect the confidentiality of the information. Medical record review for Resident 963 was initiated on 2/4/24. Resident 963 was admitted to the facility on [DATE]. On 2/4/24 at 0829 hours, during the initial tour of the facility, a medication cart was observed parked outside Room D. A clipboard with a document titled Laboratory & Pathological Services for Resident 963 was observed behind the computer on the medication cart. Resident 963's personal information was visible showing the resident's name, DOB, and CMP results with the collection date of 2/2/24. The residents and staff were observed walking in the hallway where the document was visible to them. On 2/4/24 at 0836 hours, an interview and concurrent observation was conducted with LVN 12. When asked how the facility safeguarded the resident's documents containing personal information, LVN 12 stated the computers were kept closed for everyone to see. When asked how the facility safeguarded the paper documents containing the resident's personal information, LVN 12 stated the documents were left faced down so none could see the documents, or left them covered. LVN 12 verified the lab results for Resident 963 were visible and unattended. LVN 12 stated she was not aware of the document placed behind the computer screen. LVN 12 verified the finindings and stated the lab results for Resident 963 should not have been left behind the computer screen. LVN 12 also verified the other residents and staff could definitely see Resident 963's lab results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 10 of 99 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 02/08/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 19 was initiated on 2/4/24. Resident 19 was readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 19's MDS dated [DATE], showed Resident 19 was cognitively intact. On 2/7/24 at 1411 hours, an observation and interview was conducted with Resident 19. Resident 19 was observed in bed, with some bath towels at the bedside. Resident 19 stated the facility did not have enough washcloths for the residents. When asked to elaborate, Resident 19 stated whenever she asked the CNAs to give her washcloths, the CNAs would tell her that they had ran out of washcloths and did not have washcloths anymore. On 2/8/24 at 0939 hours, an observation of the linen closets and concurrent interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated there were four linen closets in the facility. There were no washcloths observed in Linen Closets 1, 2, 3, and 4. These were verified by the Housekeeping Supervisor. The Housekeeping Supervisor stated the laundry person would deliver the clean washcloths in ten minutes. On 2/8/24 at 0948 hours, an observation of the laundry room and concurrent interview was conducted with Laundry Aide 2 and the Housekeeping Supervisor. There were 14 washcloths available in the clean linen area. When asked if they had more washcloths available for the residents to use, Laundry Aide 2 stated they did not have a lot of washcloths, and some of the washcloths were still in the dryer and clean linen bin. However, there were no washcloths observed neither in the clean linen bin nor the dryer. Laundry Aide 2 and the Housekeeping Supervisor verified the findings. The Housekeeping Supervisor stated they got complaints from the CNAs about not having enough washcloths; however, some of the CNAs also threw the washcloths and other linens in the trash. The Housekeeping Supervisor stated they informed this concern to the Maintenance Director. On 2/8/24 at 1018 hours, an observation of the emergency linen supply and concurrent interview was conducted with the Maintenance Director. When asked if he was aware if there was a shortage of washcloths in the facility, the Maintenance Director answered no, but he was aware of the staff throwing the washcloths and towels in the trash. When asked if they had more washcloths available for the residents to use, the Maintenance Director stated they had an emergency linen supply stored in a container van at the back of the facility. Upon inspection, there was no washcloths in the emergency linen supply. The Maintenance Director verified the findings. The Maintenance Director stated he would order more washcloths from their linen vendor. 5. On 2/5/24 at 1526 hours, an interview was conducted with Resident 74. Resident 74 stated his roommate had the tendency to urinate on the floor of the restroom and walked around the room and hallways with urine-soaked socks. Resident 74 stated the staff did not properly clean the restroom with disinfectant or clean the restroom when asked. On 2/7/24 at 1336 hours, an interview with CNA 12 was conducted. When asked what the process was for cleaning biological spills, CNA 12 stated the housekeeping staff were responsible, and she had not had any issues with the housekeeping staff not cleaning the rooms. CNA 12 stated the housekeeping staff cleaned it up right away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 11 of 99 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 02/08/2024 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 On 2/7/24 at 1350 hours, an interview with Housekeeping 1 was conducted. When asked what was used to clean the floors when biological spillage was noted, Housekeeping 1 stated the staff mopped first, then used a disinfectant. On 2/7/24 at 1353 hours, an interview with the Housekeeping Supervisor was conducted. When asked what the process was for cleaning biologicals off the floor, the Housekeeping Supervisor stated the CNAs would clean first, then housekeeping staff would clean with a chemical disinfectant. The Housekeeping Supervisor stated during the day, there was not an issue; but during the night shift, sometimes getting the rooms cleaned had been an issue and residents had to wait, but a resolution was executed within minutes. On 2/7/24 at 1449 hours, an observation was made of the hallways smelling of urine. On 2/8/24 at 1034 hours, an observation and interview of Resident 74 was conducted. During the observation of Resident 74's restroom, dried drops of fluid was observed on Resident 74 restroom floor, clear liquid was observed to the right side of Resident 74's toilet with crumpled up paper on the floor. On 2/8/24 at 1044 hours, the findings were verified by LVN 1. LVN 1 stated the housekeeping staff will be called to clean up the restroom, and the housekeeping staff were responsible for cleaning the floors of the restroom. 6. On 2/5/24 at 1328 hours, an interview with Resident 116 was conducted. Resident 116 stated the facility never had enough towels when providing personal care, and sometimes the resident would have to wait 30 minutes or so for towels, and the CNAs used pillowcases to clean the Resident 116. On 2/6/24 at 1419 hours, an interview with LVN 4 was conducted. LVN 4 stated she had not had any residents complained of not enough towels. LVN 4 stated the CNAs would complain there were not enough towels; and on occasion, the families would bring in wipes for the residents. 3. On 2/4/24 at 0930 hours, a large rusty dark stain was noted in Resident 128's bathtub. The shower head was also observed with some white calcium deposits surrounding it. On 2/5/24 at 0930 hours, an interview was conducted with CNA 6. CNA 6 stated the bathroom should be cleaned daily by the housekeeper; and if unable to remove stains or rusty parts found, the Maintenance Director should be notified. On 2/8/24 at 1640 hours, an interview with the Maintenance Director was conducted. The Maintenance Director stated all the residents' bathtubs and showerheads were in the process of being replaced. He would make a note to prioritize the ones with the most torn down or rusty. At this time, the residents were being asked to take their shower in the shared shower room. There were two shower rooms for each nursing station with three stalls in each room. The Maintenance Director further stated the housekeeper should do their daily rounds to ensure the residents' bathroom were cleaned and presentable. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain a clean, sanitary, and homelike environment for five of 33 final sampled residents (Residents 19, 61, 116, 122, and 128) and one nonsampled resident (Resident 74). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 12 of 99 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 02/08/2024 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 * Resident 61's window was missing four blind slats and had three broken blind slats Level of Harm - Minimal harm or potential for actual harm * Resident 122's room was observed with cracks and paint peeling on the ceiling Residents Affected - Few * The facility failed to assess Resident 128's living condition for sanitary and homelike environment, as the bathtub and showerhead were observed with presence of rusty stain and calcium deposits. * The facility failed to ensure there were adequate washcloths to be used for Resident 19 in the facility during care. * The facility failed to ensure the resident's restroom was clean and free from bodily fluids on the bathroom floor for Resident 74. * The facility failed to ensure Resident 116 had adequate towels. These failures placed the residents at risk for living in an unkempt environment. Findings: Review of the facility's P&P titled Physical Environment, Environmental Conditions/Homelike Environment revised 11/2019 showed it is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public through monthly environmental rounds. Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. 1. Medical record review for Resident 61 was initiated on 2/4/24. Resident 61 was admitted to the facility on [DATE], and readmitted on [DATE]. On 2/4/24 at 1046 hours, Resident 61's window was observed with four blind slats missing and three broken slats. On 2/4/24 at 1049 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified Resident 61's window had four blind slats missing and three broken slats. The Maintenance Director stated he noted the three broken slats from Resident 61's window; however, did not see missing slats. 2. Medical record review for Resident 122 was initiated on 2/4/24. Resident 122 was admitted to the facility on 3/212, and readmitted on [DATE]. On 2/6/24 at 1235 hours, Resident 122's room was observed with cracks and paint peeling on the ceiling around the frame of the air vent. The IP verified the findings. On 2/6/24 at 1237 hours, the Administrator verified these findings. On 2/6/24 at 1304 hours, an observation and concurrent interview was conducted with the Life Safety Resource. The Life Safety Resource verified the findings and stated there was no leaking; however, someone was cleaning the air vent and part of the paint came off. The Life Safety Resource stated it should have been taken cared of and whoever cleaned it was supposed to cut around the edge of of the air vent, and should have reported it to the maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 13 of 99 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 02/08/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one of 33 final sampled residents (Resident 116) and one nonsampled residents (Resident 153). This failure posed the risk for the residents grievances not being addressed and resolved timely. Findings: Review of the facility's P&P titled Grievances revised December 2023 showed the information is made available to the resident and/or representative and posted in designated locations throughout the facility. Information includes the resident or resident representative have the right to file a grievance orally, in writing and/or anonymously, contact information of the facility grievance office to include name, business and email address, phone number, and reasonable expected time frame for completing review of the grievance. Review of the medical records for Residents 116 and 153 was initiated on 2/4/23. The medical records showed the following: - Resident 116 was admitted on [DATE], and readmitted to the facility on [DATE]. Resident 116's H&P examination dated 4/12/23, showed the resident had the capacity to understand and make decision. - Resident 153 was admitted on [DATE], and readmitted to the facility on [DATE]. Resident 153's H&P examination dated 1/24/24, showed the resident had the capacity to understand and make decision. Review of the facility's residents council minutes dated 11/15, 12/20/23, and 1/17/24, showed no documented evidence the grievance policy addressed the information on the procedure on how to file a grievance. On 2/5/24 at 1000 hours, during the resident council meeting Residents 116 and 153 had expressed their concerns regarding filing a grievance. Residents 116 and 153 stated they were not aware on how to file a grievance. Residents 116 and 153 further stated they would like to file a grievance anonymously but did not have an access to a mailbox to submit a grievance concern. On 2/5/24 at 1105 hours, Resident 116 stated she was not fully aware about the grievance process of the facility. Resident 116 further stated she would like to file a grievance anonymously as she felt if staff were aware of the complainant, there would be retaliation that she would experience. On 2/6/24 at 1032 hours, Resident 153 was asked if he was made aware about the grievance process of the facility. Resident 153 stated he was not aware of the grievance process in the facility. Resident 153 could not remember if the facility staff discussed the grievance process upon admission to the facility. On 02/07/24 at 1307 hours, an interview with the SSD was conducted. The SSD was asked about how the facility provided information about the grievance process. The SSD stated the grievance process was usually discussed during the resident council meeting. The SSD was asked about how the other residents not attending the council meeting would be aware of the grievance process. The SSD acknowledged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 14 of 99 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 02/08/2024 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not all the residents attended the resident council meeting and would not know the process of filing a grievance. The SSD was asked what the facility's process was to file an anonymous grievance procedure. The SSD stated currently, there was no anonymous grievance filing and would check on the process the facility had in place. On 2/7/24 at 1353 hours, an interview with the Administrator was conducted. The Administrator stated the SSD should discuss grievance policy to the residents upon admission. When ask about the posting of the information regarding grievance process to be made available to the residents and residents' representatives, the Administrator stated he would post the grievance process in the location which would be visible to the residents and residents' representatives. The Administrator was asked regarding the system in place for anonymous grievance filing, the Administrator stated he would look into this matter. Event ID: Facility ID: 555765 If continuation sheet Page 15 of 99 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 02/08/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Closed medical record review for Resident 152 was initiated on 2/7/24. Resident 152 was admitted to the facility on [DATE]. Review of Resident 152's H&P examination dated 12/14/23, showed Resident 152 had the capacity to understand and make decisions. Review of Resident 152's E-Interact Transfer Form dated 1/30/24, showed Resident 152 was transferred to the acute care hospital at 2100 hours, for aggressive behavior. Further review of the closed medical record failed to show documented evidence a bed hold notice was provided to Resident 152 upon transfer to the acute care hospital. On 2/8/24 at 0930 hours, an interview was conducted with LVN 6. LVN 6 stated Resident 152 was violent when they sent him out to the acute care hospital and did not do a discussion with him for the bed hold. On 2/8/24 at 1118 hours, an interview was conducted with the SSD. The SSD verified the charge nurse was responsible for providing the bed hold notification and stated the nurse who did the transfer would initiate the bed hold at the time of discharge. On 2/8/24 at 1654 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents or the residents' representative were provided written or verbal notice of the facility's bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care hospital for one of 33 final sampled residents (Resident 29) and one closed record sample resident (Resident 152). This failure had the potential for the residents and the residents' representative to be unaware of their rights to return to the facility following a hospitalization. Findings: Review of the facility's P&P titled Admission/Discharge/ Transfer, Bed Hold revised 11/2016 showed it is the facility's policy to inform the resident, or the resident's representative, in writing, of the right to exercise the bed hold provision of seven days, upon admission and before transfer to a general acute hospital or before the resident goes on therapeutic leave. 1. Medical record review for Resident 29 was initiated on 2/4/24. Resident 29 was readmitted to the facility on [DATE]. Review of Resident 29's MDS dated [DATE], showed Resident 29's cognitive skills for daily decision making was severely impaired. Review of Resident 29's eINTERACT Change in Condition Evaluation V4.2 dated 1/24/24, showed Resident 29 was transferred to the acute care hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 16 of 99 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 02/08/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 29's Bed Hold Notification showed Resident 29's representative signed the form on 9/21/23 (on admission). Further review of the medical record showed the sections for Confirmation of Transfer and Bed Hold Provision and 24-hour Notification were left blank. Review of Resident 29's medical record failed to show documented evidence Resident 29's representative was notified of the bed hold provision when the resident was transferred to the acute care hospital on 1/24/24. On 2/6/24 at 1007 hours, an interview and concurrent medical record review was conducted the DON. The DON verified the above findings. The DON stated the licensed nurses were responsible to notify the resident and/or their representative of the bed hold provision and complete the Bed Hold Notification form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 17 of 99 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 02/08/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, and facility P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level II determination was followed up and incorporated into the resident care for one of 33 final sampled residents (Resident 99). This failure had the potential for Resident 99 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by a appropriate state-designated authority. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised January 2022 showed the facility IDT will develop and implement a comprehensive person centered care plan for each resident within seven days of completion of the resident minimum data set and will include resident needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident goals and desired outcomes, preferences for future discharge and discharge plans. Medical record review for Resident 99 was initiated on 2/5/24. Resident 99 was admitted to the facility on [DATE]. Review of Resident 99's H&P examination dated 6/26/23, showed Resident 99 was able to make decisions. Review of the letter sent to Resident 99 by the Department of Health Care Services dated 7/9/23, showed the PASARR level II evaluation was conducted on 7/7/23. The letter further showed the facility staff would receive the copy of the determination report and discuss the result with Resident 99 and would incorporate the recommendations into Resident 99's care plan. Review of Resident 99's PASARR Individualized Determination Report dated 7/9/23, showed Resident 99 required nursing facility services due to a medical and/or mental health condition. The PASARR Individualized Determination Report further showed special services were recommended. Review of the Resident 99's medical record did not show the recommendations from the PASARR Individualized Determination Report was followed up. Review of the Resident 99's Care Plan did not show a care plan problem addressing the recommendations from the PASARR Individualized Determination Report. On 2/6/24 at 1244 hours, an interview and a concurrent record review for Resident 99 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated she was not able to find documented evidence showing the recommendations from the PASARR level II determination was followed up. The MDS Coordinator reviewed the care plan and stated she was not able to find the care plan problem addressing the recommendation for specialized services as per the PASARR Individualized Determination Report. The MDS Coordinator stated Resident 99 was receiving services recommended from PASARR level II determination even before PASARR level II evaluation was conducted and were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 18 of 99 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 02/08/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete already part of the Resident 99's care plan. However, the MDS Coordinator stated the care plan did not address the PASSAR level II evaluation and its result. The MDS Coordinator acknowledged there was a possibility the recommendation from the PASSAR level II evaluation could have been missed. On 2/7/24 at 1617 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings. Event ID: Facility ID: 555765 If continuation sheet Page 19 of 99 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 02/08/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **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 baseline care plan for one of 33 final sampled residents (Resident 133) were initiated upon admission. * The facility failed to ensure Resident 133's baseline care plan included the necessary information to properly care for the resident with the history of fluctuating weights, necessary nutritional interventions to maintain or prevent further weight loss, and individualized activity care plan to appropriate for the resident. This failure had the potential for Resident 133 not receiving necessary resident-centered care. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated November 2016 showed within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social services; and f) PASARR recommendations; if applicable Medical record review for Resident 133 was initiated on 2/5/24. Resident 133 was admitted to facility on 9/22/23 and was readmitted on [DATE]. Review of the H&P examination dated 12/21/23, showed Resident 133 had no capacity to understand and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 20 of 99 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 02/08/2024 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 0655 make decision. Level of Harm - Minimal harm or potential for actual harm Review of Resident 133's Order Summary Report for February 2024 showed an enteral feeding order on 2/5/24, to provide Jevity 1.5 (enteral feeding formula) via GT at 66 ml/hr. for 20 hrs to provide 1320 ml of fluid, 1980 calories, 84.2 grams of protein, and 175 ml of water flushing every four hours to provide a total of 1050 ml water. Residents Affected - Few Review of Resident 133's weights showed the following: - on 9/23/23, 129 lbs. - on 10/2/23, 129 lbs. - on 10/9/23, 128 lbs. - on 10/16/23, 126 lbs. - on 10/23/23, 126 lbs. - on 11/3/23, 130 lbs. - on 12/4/23, 120 lbs. - on 12/21/23, 126 lbs. - on 12/25/23, 126 lbs. - on 1/1/24, 126 lbs. - on 1/29/24, 121 lbs. Further review of resident's care plan failed to identify the resident's individualized goal and interventions to try to stabilize or improve nutritional status. On 2/4/24 at 0938 hours, an observation of Resident 133 was conducted. Resident 133 was lying in bed quietly with GT feeding of Jevity 1.5 infusing at 66 ml/ hr. with water flush at 44 ml/hr. On 2/6/24 at 1041 hours, an interview was conducted with the RD. The RD stated the resident weight loss was related to the recent hospitalization. The RD was asked about the resident's weight fluctuation since September 2023. The RD stated she would check on Resident 133's weight records. On 2/6/24 at 1335 hours, a concurrent interview and medical record review was with the RD. The RD stated the resident's weight loss was not alarming as Resident 133 was still within the +/- 10% of ideal body weight of 124 pounds. Resident 133's care plan was reviewed with the RD. The RD verified Resident 133's care plan failed to address the goal for the resident and interventions to maintain or prevent further weight loss. On 2/7/24 at 1041 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 133's baseline care plan failed to identify the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 21 of 99 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 02/08/2024 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 0655 individualized goals and interventions to try to stabilize or improve nutritional status. The DON was informed and acknowledged the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 22 of 99 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 02/08/2024 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 0656 Level of Harm - Potential for minimal harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the use of oxygen therapy for two of 33 final sampled residents (Resident 128) and one nonsampled resident (Resident 662). This failure had the potential for not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised January 2022 showed the comprehensive, person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 1. On 2/4/24 at 0912 and 1100 hours, during an observation, Resident 662 was observed receiving oxygen at 5 liters per minute via nasal cannula. Medical record review for Resident 662 was initiated on 2/4/24. Resident 662 was admitted to the facility on [DATE]. Review of Resident 662's Care Plan did not show a documented evidence a care plan problem was developed to address the resident's use of oxygen therapy. On 2/4/24 at 1100 hours, a concurrent observation, interview, and medical record review for Resident 662 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated there should have been a care plan initiated for Resident 662's oxygen therapy. On 2/7/24 at 1617 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the oxygen was a therapy and it required a care plan. The DON stated a care plan for the oxygen therapy for Resident 662 should have been initiated. 2. Review of the facility's P&P titled Comprehensive Person-Centered Care Plan dated 1/22 showed a baseline care plan is required when any type of therapy is initiated. On 2/4/24 at 0930 hours, Resident 128 was observed lying in bed and receiving oxygen via nasal cannula at the rate of 4.5 L/min. Resident 128 stated he had been using the oxygen since he was admitted to this facility on 1/8/24. Review of the medical reocrd for Resident 128 was initiated on 2/4/24 at 0940 hours. Review of the Progress Note dated 2/4/24, showed Resident 128 with medical history of chronic respiratory failure with hypoxia. Further review of the resident' Daily Skilled/Condition Monitoring dated 1/8 to 2/4/24, showed the resident's oxygen saturation levels had been recorded daily with the oxygen method use via nasal cannula. Review of the Order Summary Report for February 2024 showed no physician order for the oxygen therapy or a care plan was developed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 23 of 99 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 02/08/2024 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 0656 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/6/24 at 1025 hours, an interview was conducted with LVN 8 regarding plan of care for the oxygen therapy. LVN 8 stated the RN was in charge of establishing plan of care for the resident. On 2/6/24 at 1425 hours, an interview was conducted with RN 1. RN 1 confirmed Resident 128 did not have a care plan developed for the resident's oxygen therapy. RN 1 further stated a care plan was necessary to evaluate the effectiveness of the oxygen use. Event ID: Facility ID: 555765 If continuation sheet Page 24 of 99 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 02/08/2024 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 - Potential for minimal harm Residents Affected - Some 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 33 final sampled residents (Resident 1) and one nonsampled resident (Resident 762) were revised to reflect the residents' current care needs and interventions. * Resident 762's care plan for obstructive sleep apnea (occurs when the upper airway becomes blocked, leading to brief pauses in breathing during sleep) was not revised to address the current CPAP (machine used to provide mild air pressure to keep breathing airways open during sleep) order. * The facility failed to ensure Resident 1's plan of care was revised to reflect the use of hydrocodone-acetaminophen (Norco is used to relieve moderate to severe pain). These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised 1/2022 showed the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The policy also showed the resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments. 1. During the initial tour of the facility on 2/4/24 at 1238 hours, an observation and concurrent interview was conducted with Resident 762. Resident 762 was observed in bed with the CPAP machine observed at bedside. Resident 762 stated he used the CPAP every night. Medical record review for Resident 762 was initiated on 2/4/24. Resident 762 was admitted to the facility on [DATE]. Review of Resident 762's H&P examination dated 1/22/24, showed Resident 762 had the capacity to understand and make decisions and had obstructive sleep apnea. Review of Resident 762's Order Summary Report for February 2024 showed a physician's order dated 1/26/24, to use CPAP from home with the same settings at bedtime (from 2200 hours to 0600 hours per the resident's preference) for sleep apnea. Review of Resident 762's plan of care showed a care plan problem revised 1/21/24, addressing the resident's altered respiratory status/difficulty breathing related to obstructive sleep apnea. However, the plan of care was not revised to reflect Resident 762's CPAP use as per the physician's order. On 2/5/24 at 1510 hours, an interview and concurrent medical record review was conducted with LVN 14. LVN 14 verified the above findings. On 2/5/24 at 1515 hours, an interview and concurrent medical record review was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 25 of 99 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 02/08/2024 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 - Potential for minimal harm Residents Affected - Some MDS Coordinator. The MDS Coordinator verified Resident 762's plan of care addressing his obstructive sleep apnea was not revised to reflect Resident 762's CPAP use per the physician's order. The MDS Coordinator stated the licensed nurses who received and documented the physician's order in the resident's medical record should update the plan of care. On 2/6/24 at 0952 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 2. Medical record review for Resident 1 was initiated on 2/5/24. Resident 1 was admitted to facility on 7/29/22 and readmitted on [DATE]. Review of the H&P examination dated on 1/13/24, showed Resident 1 was able to make needs known and his own decision. Review of Resident 1's Order Summary Report for February 2024 showed a physician's order on 1/9/24, to administer Norco oral tablet 7.5-325 mg one tablet by mouth every six hours as needed for moderate pain, a pain level of 4-6 (on a 0=10 pain scale, with 0=no pain and 10=worst pain) and Norco oral tablet 7.5-325 mg two tablets by mouth every six hours as needed for severe pain, a pain level of 7-10. Review of Resident 1's care plan problem addressing the potential for an adverse outcomes from opioid use dated 1/7/24, showed the use of an opioid (Dilaudid). There was no entry for the use of the Norco medication. On 2/6/24 at 1004 hours, a concurrent interview and medical record review was conducted with LVN 6. LVN 6 stated Resident 1 sometimes complained of pain and was previously taking Dilaudid when the resident was on hospice services. LVN 6 stated when Resident 1 was discharged from hospice services, the pain medication was changed to Norco. Resident 1's care plan problem was reviewed with LVN 6. LVN 6 verified Resident 1's care plan problem did not reflect the use of Norco. On 2/7/24 at 0911 hours, a concurrent interview and medical record review was conducted with the DON. The DON was made aware of the above findings. The DON reviewed Resident 1's care plan and stated the resident's care plan needed a revision to reflect use of Norco. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 26 of 99 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 02/08/2024 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 0679 Provide activities to meet all resident's needs. 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 care plans for two of 33 final sampled residents (Residents 133 and 812) were developed to address the residents' activities. Residents Affected - Few * The facility failed to ensure Resident 133 and 812's care plans included the individualized activity care plans to provide the appropriate activities for the residents. This failure posed the risk for Residents 133 and 812 not receiving the necessary resident-centered care. Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated November 2016 showed within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social services; and f) PASARR recommendations; if applicable 1. Medical record review for Resident 133 was initiated on 2/5/24. Resident 133 was admitted to facility on 9/22/23, and readmitted on [DATE]. Review of the H&P examination dated 12/21/23, showed Resident 133 had no capacity to understand and make decision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 27 of 99 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 02/08/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/4/24 at 1240 hours, an observation of Resident 133 was conducted. Resident 133 was observed lying in bed with drapes drawn closed. Resident 133 was verbally responsive; however, speaking Mandarin. No TV or music was observed provided to the resident. No activities were provided for Resident 133. On 2/4/24 at 1400 hours, an interview was conducted with CNA 13. CNA 13 stated Resident 133 usually stayed in his room and sometimes being visited by the wife. On 2/6/24 at 0900 hours, an observation of Resident 133 was conducted. Resident 133 was observed in room sound asleep with drapes drawn closed. No activities was observed. On 2/7/24 at 0903 hours, a concurrent interview and medical record review was conducted with the Activity Director. The Activity Director stated Resident 133 was Mandarin speaking, sometimes the Activity Director visited Resident 133 and provided hand massage to the resident. Review of Resident 133's care plan was conducted with the Activity Director. The Activity Director verified Resident 133's plan of care failed to show an activity care plan problem to address the individualized activity program for the resident. On 2/7/24 at 1041 hours, a concurrent interview and medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 812 was initiated on 2/5/24. Resident 812 was admitted [DATE]. On 2/4/24 at 0921 hours, during the initial tour, Resident 812 was observed lying on bed. Resident 812 stated she usually stayed in bed most of the time. Resident 812 verbalized she had not attended any activities in the facility and would like to attend and see the activities offered by the facility. On 2/6/24 at 1626 hours, Resident 812 was observed lying in bed using her cell phone. On 2/7/24 at 0838 hours, a concurrent interview and record review was conducted with the Activity Director. The Activity Director stated she had not seen the resident since admission. The Activity Director failed to show an activity care plan to address an individualized activity program for the resident. The Activity Director verified a care plan problem for activities was not initiated for Resident 812. On 2/7/24 at 1041 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Resident 812's baseline care plan failed to show the activity care plan problem to address an individualized activity program for the resident. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 28 of 99 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 02/08/2024 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 services to attain or maintain the highest practicable well-being for five of 33 final sampled residents (Residents 12, 31, 107, 105, and 1012) and one nonsampled resident (Resident 39). Residents Affected - Few * The facility failed to ensure the systolic blood pressure and heart rate for Resident 107 were monitored before administering carvedilol (anihypertensive medication) medication as per the physician's order. * The facility failed to ensure the systolic blood pressure and heart rate for Resident 105 were monitored before administering amlodipine (antihypertensive medication) hydralazine (antihypertensive medication) medications as per the physician's order. * The facility failed to ensure the injection sites for lantus (insulin) administration for Resident 12 were rotated as per the physician's order. * The facility failed to ensure a Change in Condition was completed for Residents 31 and 1012 when the residents were diagnosed with COVID-19. * The facility failed to ensure Resident 39 was assessed and monitored after a fall incident. These failures had the potential to negatively affect the residents' health condition and well-being. Findings: 1. Medical record review for Resident 107 was initiated on 2/4/24. Resident 107 was readmitted to the facility on [DATE]. Review of Resident 107's Order Summary Report showed a physician's order dated 10/3/23, to administer carvedilol 12.5 mg two times a day for hypertension and hold if systolic blood pressure less than 110 mmHg or heart rate less than 60 beats per minute. Review of Resident 107's MAR for January and February 2024 showed Resident 107 was administered the carvedilol medication from 1/1 to 1/11/24, 1/13 to 1/23/24, 1/25, 1/26, 1/28 to 2/3/24 at 0900 hours; and 1/1 to 1/10/24, 1/13 to 1/18/24, 1/20, 1/21, 1/26, 1/29 to 2/1/24 at 1700 hours. However, there was no documented evidence to show Resident 107's systolic blood pressure and heart rate were monitored prior to administering the carvedilol medication to the resident. On 2/7/24 at 1310 hours, an interview and concurrent medical record review for Resident 107 was conducted with the DON. The DON verified there was no documented evidence to show Resident 107's systolic blood pressure and heart rate were monitored prior to administering the carvedilol medication to the resident. 2. Medical record review for Resident 105 was initiated on 2/4/24. Resident 105 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 29 of 99 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 02/08/2024 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 Review of Resident 105's Order Summary Report showed the following physician's orders: Level of Harm - Minimal harm or potential for actual harm -On 12/21/23, to administer amlodipine 10 mg one time a day for hypertension and hold if systolic blood pressure less than 110 mmHg or heart rate less than 60 beats per minute; and Residents Affected - Few -On 1/24/24, to administer hydralazine 25 mg three times a day for hypertension and hold if systolic blood pressure less than 110 mmHg or heart rate less than 60 beats per minute. Review of Resident 105's MAR for January and February 2024 showed the following: -Resident 105 was administered with the amlodipine medication from 1/1 to 1/16/24, and 1/24 to 2/6/24 at 0900 hours; and -Resident 105 was administered with the hydralazine medication from 1/24 to 2/6/24 at 0900, 1300, and 1700 hours However, there was no documented evidence to show Resident 105's systolic blood pressure and heart rate were monitored prior to administering the amlodipine and hydralazine medications to the resident. On 2/7/24 at 1340 hours, an interview and concurrent medical record review for Resident 105 was conducted with the DON. The DON verified the above findings. 3. According to Taylor's Clinical Nursing Skills seventh edition, the various sites used for subcutaneous injections are the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crest), the anterior aspect of the thigh, the upper back, and the upper ventral (front upper) or dorsogluteal area (buttocks). It is necessary to rotate sites or areas for injection to prevent buildup of fibrous tissue and permits complete absorption of the medication. Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 8/22/23, to administer Lantus solution (antidiabetic medication) 14 units subcutaneously at bedtime, hold of the blood sugar level less than 100 mg/dl, and rotate injection sites. Review of Resident 12's MAR for January and February 2024 showed Resident 12 was administered with 14 units of Lantus medication from 1/1 to 2/6/24 at 2100 hours. Review of Resident 12's Location of Administration Report for January 2024 showed Resident 12 received the Lantus medication on the left arm from 1/1 to 1/28/24. Review of Resident 12's Location of Administration Report for February 2024 showed Resident 12 received the Lantus medication on the right arm from 2/1 to 2/6/24. On 2/7/24 at 1250 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON verified the injection sites for the Lantus injection were not rotated for Resident 12. There was no documentation to show Resident 12 preferred the left arm or the right arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 30 of 99 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 02/08/2024 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 4. Review of the facility's P&P titled Change of Condition Reporting revised 2/23 showed the facility must document the resident's change of condition and response in eINTERACT Change of Condition UDA. Medical record reviews for Residents 31 and 1012 were initiated on 2/4/24. Resident 31 was admitted to the facility on [DATE]. Resident 1012 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 31's medical record showed no eINTERACT Change of Condition UDA addressing the resident's COVID diagnosis. Review of Resident 1012's medical record showed no eINTERACT Change of Condition UDA addressing the resident's COVID diagnosis. On 2/7/24 at 1309 hours, an interview was conducted with the DSD/IP. When asked for the list of the residents who were diagnosed with COVID during their recent COVID outbreak on 1/16/24, which included Residents 1 and 1012, the DSD/IP stated Residents 31 and 1012 were diagnosed with COVID on 1/31/24, as part of their COVID response testing. On 2/8/24 at 1623 hours, a concurrent follow-up interview and medical record review was conducted with the DSD/IP. When asked about the Change of Condition process, the DSD/IP stated the nurse should complete the eINTERACT Change of Condition UDA form when a resident had a change in condition. When asked about Residents 31 and 1012, the DSD/IP verified there was no Change of Condition form completed when the residents were diagnosed with COVID on 1/31/24. The DSD/IP stated an eINTERACT Change of Condition UDA form should have been completed for those residents even though they did not have COVID symptoms. On 2/8/24 at 1757 hours, the DON and Corporate Clinical Resource were informed and acknowledge the above findings. 5. 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. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the Nursing Progress Notes. The Attending Physician and family/responsible party shall be notified of the fall and the resident status. Follow-up assessment and documentation will be conducted for a minimum of 72 hours following the incident. Review of the facility's P&P titled Change of Condition Reporting revised 2/2023 showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. Any change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. If unable to contact attending physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least 72 hours or until condition has stabled. Review of the facility's P&P titled Unusual Occurrences, undated, showed an unusual occurrences shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or telegraph to the local health officer and the Department. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 31 of 99 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 02/08/2024 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 Medical record review for Resident 39 was initiated on 2/6/24. Resident 39 was readmitted to the facility on [DATE]. Review of Resident 39's MD Visit Note dated 10/9/23, showed Resident 39 was frail and required assistance for ADL care. Residents Affected - Few Review of Resident 39's MDS dated [DATE], showed Resident 39's cognitive skills for daily decision making was severely impaired and dependent on staff for transfers. Review of Resident 39's eINTERACT Change in Condition Evaluation dated 1/27/24, showed Resident 39 had a change indicating a discoloration to her medial aspect of right knee starting on 1/27/24. The document showed the physician was notified; however, there was no recommendation from the physician. Further review of Resident 39's medical record failed to show Resident 39's physician was followed up with or the medical director was contacted for the change of condition on 1/27/24. There was no dcoumented evidence of assessment and monitoring after the change in condition. Review of Resident 39's Rehabilitation Services Screening Tool dated 2/1/24, showed Resident 39 had a change of status in her ROM to upper extremities and lower extremities and showed Resident 39 had pain. The therapist recommended an RNA program for gentle PROM exercises to BUE's and BLE's three times a week as tolerated. Review of Resident 39's Joint Mobility Evaluation, dated 2/1/24, showed Resident 39's joint mobility had worsened since the last assessment. The changes showed Resident 39 had a decreased ROM in the left shoulder, right hip and both knees and ankles, decreased strength in UE's and LE's with complaints of pain in the right lower extremity, left shoulder, and LLE during movement. The RNA orders were to be changed to PROM vs AROM exercises. Review of Resident 39's Order Summary Report showed a physician's order dated 2/2/24, for an x-ray of the bilateral knees for complaint of pain with PROM. Review of the Resident 39's Radiology Interpretation dated 2/3/24, showed Resident 39's left knee two view x-ray impression showed osteoporosis with oblique fracture distal femur. Further review of the medical record showed the resident was transferred to the acute care hospital on 2/3/24. Review of Resident 39's Nursing progress note dated 2/5/24, showed a late entry for 2/2/24 at 1400 hours, CNA reported Resident 39 had facial grimacing while providing care; per attending NP, bilateral knees x-ray was ordered. Resident 39 was resting comfortably in bed after care, will continue to monitor, will inform MD for any changes, and endorsed to the PM shift for follow up. Review of Resident 39's Change in Condition note dated 2/5/24, showed on 1/26/24 at approximately 1430 hours, CNA reported an assisted fall. The note stated the NP was notified on 1/26/24, and there were no new orders at this time. On 2/6/24 at 0846 hours, an interview was conducted with CNA 3. CNA 3 was asked about Resident 39's activity level. CNA 3 stated Resident 39 had no activity, and she had a lot of pain when they moved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 32 of 99 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 02/08/2024 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 her. Level of Harm - Minimal harm or potential for actual harm On 2/6/24 at 0850 hours, an interview was conducted with RNA 1. RNA 1 stated Resident 39 was discharged from RNA service on 1/31/24. RNA 1 stated RNA services was discontinued because he saw Resident 39 had discomfort, pain, and could not follow the routine. RNA 1 stated he reported the purple discoloration on Resident 39's right knee and her condition to the rehabilation and charge nurse. Residents Affected - Few On 2/6/24 at 0913 hours, a concurrent interview and medical record review was conducted with LVN 3 about Resident 39's sustained a fracture and fall incident on 1/26/24. LVN 3 stated CNA 5 reported when doing a transfer of Resident 39 from the bed to the wheelchair, the resident got heavy for her, and CNA 5 guided her down to the floor. LVN 3 stated he asked Resident 39 if she was okay and checked her hip, knee, shoulder, and lower back. LVN 3 stated she was okay, and they picked Resident 39 up and put her back in bed. LVN 3 stated he assessed Resident 39, did not see any injuries, and decided to just monitor and passed it on. LVN 3 stated he did not know this was considered a fall. LVN 3 stated the next day, Resident 39's medial right knee had discoloration and he reported this to the physician; however, verified he did not get a response and passed it on to the next nurse. LVN 3 verified there was no followed up with the physician until the x-rays were ordered on 2/2/24. On 2/6/24 at 0959 hours, a concurrent interview and medical record review was conducted with RN 1 about Resident 39's change of condition. RN 1 verified there was no documented evidence Resident 39 sustained a fall on 1/26/24. RN 1 verified Resident 39's fall was not documented as a change of condition until 2/5/24, and should have been documented on the same day, 1/26/24. RN 1 verified there were no skin assessment completed, nursing progress note, and 72 hour monitoring completed for Resident 39's fall on 1/26/24. RN 1 then reviewed the 1/27/24 change of condition of discoloration on the medial aspect of right knee. RN 1 verified the discoloration was new, the physician was notified on 1/27/24, and there was no documentation of recommendations. RN 1 verified there was no followed up with the physician until 2/3/24, when the x-rays were taken. On 2/6/24 at 1235 hours, a follow-up interview and concurrent medical record review was conducted with LVN 3 about Resident 39's fall in her room. LVN 3 stated Resident 39 looked like she was propping herself up from the floor and had one hand on the bed and the other on the ground; her left leg was kind of straight and the right leg was bent with her knee facing the door. LVN 3 verified a change of condition documentation for the fall on 1/26/24, was not completed until 2/5/24. LVN 3 reviewed the documentation regarding notification to the provider and verified he made a mistake on the documentation and did not notify the provider about the fall on 1/26/24. On 2/6/24 at 1600 hours, a concurrent interview and medical record review was conducted with the DON. The DON acknowledged the above findings. The DON verified Resident 39 had an assisted fall on 1/26/24, while transferring from the bed to wheelchair. The DON stated CNA 5 sat Resident 39 down so LVN 3 did not consider this a fall. The DON stated an assisted fall was a fall. The DON verified there was no report of Resident 39's assisted fall. The DON verified there was no followed up with the physician for Resident 39's change of condition on 1/27/24, until 2/2/24. On 2/7/24 at 0859 hours, an interview was conducted with CNA 5. CNA 5 stated there were no slings and the hoyer lift did not work, and she tried to get Resident 39 up to the chair. CNA 5 stated usually they had two people, but everyone was busy on that day and verified she attempted to transfer Resident 39 by herself. CNA 5 stated Resident 39's body was wobbly and she assisted Resident 39 to the floor and sat her down on her bottom. CNA 5 stated she called LVN 3, and LVN 3 lifted the resident and put her back in the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 33 of 99 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 02/08/2024 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 On 2/7/24 at 0947 hours, a follow-up interview and medical record review was conducted with the DON. The DON stated they found out about the discoloration on Resident 39's right knee on 2/3/23, with the x-ray report and verified she was not aware of Resident 39's fall until 2/5/24, after they started interviewing staff. The DON verified the fracture was considered an unusual occurrence and was not reported timely within 24 hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 34 of 99 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 02/08/2024 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, medical record review, and facility P&P review the facility failed to provide the necessary care and services related to pressure injury for two of 33 final sampled residents (Residents 61 and 94). Residents Affected - Few * The facility failed to ensure the bilateral heel protectors were provided as ordered by the physician for Residents 61 and 94. This failure posed the risk for skin breakdown for these residents. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 12/2023 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. 1. Medical record review for Resident 61 was initiated on 2/4/24. Resident 61 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 61's Order Summary Report showed a physician's order dated 5/5/23, for bilateral heel protectors, may remove daily for skin checks every day shift. Review of Resident 61's Plan of Care showed a care plan problem dated 6/19/23, addressing the potential impairment to skin integrity related to fragile skin, limited mobility, episodes of incontinence, and history of right medial foot SDTI. The interventions included BLE heel protectors when in bed, may remove for skin checks. On 2/7/24 at 1352 hours, an observation and concurrent interview was conducted with CNA 9. CNA 9 was observed placing a pillow under Resident 61's legs; however, there were no heel protectors in place. CNA 9 verified there were no heel protectors applied to Resident 61 and stated she could not locate the heel protectors in Resident 61's room. 2. Medical record review for Resident 94 was initiated on 2/4/24. Resident 94 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 94's Order Summary Report dated 2/8/24, showed a physician's order dated 2/6/24, for bilateral heel protectors for skin management, may remove for skin checks and treatment every shift. On 2/7/24 at 0800 hours, an observation was conducted for Resident 94. Resident 94 was sitting upright in bed with no bilateral heel protector. On 2/7/24 at 0900 hours, an observation and concurrent interview was conducted with LVN 7. LVN 7 verified the findings. On 2/7/24 at 0930 hours, and interview was conducted with CNA 12. CNA 12 verified Resident 94 received total care. CNA 12 also verified Resident 94 was not provided with the heel protectors in the morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 35 of 99 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 02/08/2024 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 On 2/7/24 at 1034 hours, an observation and concurrent interview was conducted with LVN 3. Resident 94 did not have heel protectors applied to both heels as ordered by the physician. LVN 3 verified the findings. Furthermore, LVN 3 could not locate the heel protectors in Resident 94's room. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 36 of 99 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 02/08/2024 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the adequate assistance and supervision were provided for two of 33 sampled residents (Residents 49 and 122). * The facility failed to ensure a portable space heater was not plugged in Resident 49's room at bedside. This failure provide an accident hazard for the resident and the facility in case of malfunction, and fire. * The facility failed to ensure Resident 122's tab alarm was attached to the resident. Furthermore, the facility failed to obtain directions for the use of the tab alarm. These failures had the potential to negatively impact the residents' well-being and increase the risk of the residents for more accidents which may result in further injuries. 1. On 2/4/24 at 0824 hours, during the initial facility tour, an observation and concurrent interview was conducted with Resident 49. A portable space heater was observed plugged directly into an outlet on the wall, and approximately six inches from the resident's bed. The portable space heater was turned off and not in use. Resident 49 stated he would use it when the room gets cold. Resident 49 stated the maintenance helped him when he had an issue with the portable heater. Medical record review for Resident 49 was initiated on 2/4/24. Resident 49 was readmitted to the facility on [DATE]. Review of Resident 49's MDS dated [DATE], showed Resident 49 was cognitively intact. On 2/5/24 at 1028 hours, the portable space heater was still observed plugged directly into an outlet on the wall, approximately six inches from the resident's bed. The portable space heater was turned off and not in use. Resident 49 stated he used the heater two weeks ago when the room was 42 degrees F. On 2/5/24 at 1029 hours, an observation for Resident 49 and concurrent interview was conducted with LVN 17. LVN 17 verified the portable space heater inside Resident 49's room. LVN 17 stated she was not aware Resident 49 had a portable heater inside his room. LVN 17 stated the residents were not allowed to have a portable heater inside their room. On 2/5/24 at 1040 hours, an interview was conducted with the Life Safety Resource. The Life Safety Resource stated the residents were not allowed to have a portable heater in their room. The Life Safety Resource checked the room temperature at 74.1 degrees F. The Life Safety Resource stated the residents should let the staff know when they had a concern with the room temperature. 2. Medical record review for Resident 122 was initiated on 2/4/23. Resident 122 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 122's Order Summary Report showed the physician's orders dated 5/9/23, for tab alarm while in bed and wheelchair every shift. The physician's orders failed to show indication for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 37 of 99 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 02/08/2024 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 the use of tab alarm. Level of Harm - Minimal harm or potential for actual harm On 2/5/24 at 0936 hours, an observation for Resident 122 and concurrent interview was conducted with RNA 1. Resident 122 was observed in bed. The tab alarm was observed attached to the right side of the bed frame; however, the cord and clip of the tab alarm was not attached to Resident 122. The tab alarm's clip with cord was hanging over the right side of Resident 122's bed frame. RNA 1 verified the findings and attached the clip to Resident 122's gown at the right shoulder area. Residents Affected - Few On 2/6/24 at 1225 hours, Resident 122 was observed sitting in her wheelchair in her room. Resident 122's tab alarm was not attached to Resident 122. The tab alarm clip was hung over the back of Resident 122's wheelchair. When the clip was properly attached to the resident and the resident tried to get up, the tab attached to the cord would detach from the tab alarm causing an alarm sound to alert staff. On 2/6/24 at 1229 hours, an observation and concurrent interview was conducted with the IP. The IP stated she was not familiar with the device, however, verified the tab alarm clip was not attached to Resident 122's clothing. The IP stated she worked in the facility for a week and a half and requested to be educated regarding the tab alarm. On 2/6/24 at 1233 hours, the DSD came inside Resident 122's room. The DSD verified the tab alarm was supposed to have been attached to the resident while Resident 122 was either up in the wheelchair or in bed. On 2/8/24, at 1439 hours, the DSD verified she was not able to find documentation showing an inservice was conducted with staff regarding the use of tab alarm. The DSD also verified Resident 122's physician's order for the tab alarm did not include the indication for use and should have been included in the physician's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 38 of 99 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 02/08/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure one of 33 final sampled residents (Resident 12)'s hydration needs were met. Residents Affected - Few * The facility failed to monitor Resident 12's intake and output as per the physician's order. This failure had the potiential to negatively affect the resident's health and well-being. Findings: Review of the facility's P&P titled Intake and Output Documentation revised 6/2023 showed it is the policy of the facility to maintain a measurement of a resident's intake and output to assess fluid balance when indicated by the resident's clinical condition if ordered by the physician. This shall be reviewed and monitored by the license nurse. Measure and record all liquids taken by the resident on intake and output monitoring. Records of enteral and IV intake may be recorded on the MAR or electronic MAR in lieu of the intake and output record. Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 was cognitively intact. Review of Resident 12's Order Summary Report showed the following physician's orders: - On 9/31/21, for fluid restriction secondary to heart failure. To monitor intake and output every shift on 1200 cc. Fluid restriction as follows: dietary 720 cc (breakfast 240 cc, lunch 240 cc, and dinner 240 cc); and 200 cc for nursing from 0700 to 1500 shift, 200 cc for nursing from 1500 to 2300 hours, and 80 cc for nursing from 2300 to 0700 hours; - On 4/2/21, to monitor intake and output daily total every evening shift; - On 4/2/21, for weekly intake and output evaluation every evening shift every Saturday; and - On 9/27/22, for indwelling catheter French 16/10 ml. Review of Resident 12's MAR for January and February 2024 showed the following: - There was no documented evidence the resident's daily intake and output for every shift were monitored; - The checkmarks were documented from 1/1 to 2/6/24, for the monitoring of intake and output daily totals every evening shift. However, there was no documented evidence a daily intake and output total was monitored; and - The checkmarks were documented on 1/6, 1/13, 1/20, 1/27, and 2/3/24, for the weekly intake and output evaluation every evening shift every Saturday. There was no documented evidence a weekly intake and output evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 39 of 99 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 02/08/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 12's plan of care showed a care plan problem revised 4/28/22, addressing Resident 12's refusal to have a measured water pitcher at bedside for fluid restriction monitoring. Further review of Resident 12's medical record review did not show documented evidence Resident 12's fluid intake and output were documented every shift, and the daily fluid intake and output was monitored daily and evaluated weekly. On 2/6/24 at 1323 hours, an observation and concurrent interview was conducted with Resident 12. Resident 12 was observed in bed. A plastic water bottle containing water and lemon was observed at bedside. Resident 12 also had an indwelling urinary catheter. When asked about her fluid intake, Resident 12 stated she did not want the staff to measure how much fluid she had taken, and she mainly drank the lemon water that she had at the bedside. On 2/7/24 at 1250 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON verified the above findings. The DON stated the licensed nurses were supposed to document the intake and output every shift, monitor the daily intake and output total, and evaluate the weekly intake and output every Saturday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 40 of 99 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 02/08/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services were provided to two of 33 final sampled residents (Residents 29 and 110). * The facility failed to ensure Resident 29's enteral syringe was labeled and dated. * The facility failed to ensure Resident 110's enteral syringe was changed daily as per the facility's policy. These failures posed the risk for complications related to the use of the enteral feeding for Residents 29 and 110. Findings: Review of the facility's P&P titled Medical Equipment, Storage, Labeling, Cleaning and Disinfecting revised 5/2020 showed it is the facility's policy to provide areas, equipment, and supplies to implement its Infection Control Program. The policy also showed enteral syringes are changed daily and as needed. 1. During the initial tour of the facility on 2/4/24 at 1031 hours, an observation was conducted with Resident 29. Resident 29 was observed in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 29's enteral syringe was stored inside a clear plastic storage bag without the resident's name, date, and time. Medical record review for Resident 29 was initiated on 2/4/24. Resident 29 was readmitted to the facility on [DATE]. Review of Resident 29's MDS dated [DATE], showed Resident 29's cognitive skills for daily decision making was severely impaired. Review of Resident 29's H&P examination note dated 1/29/24, showed Resident 29 had a GT, and to continue the tube feeding. On 2/5/24 at 1300 hours, an observation was conducted with Resident 29. Resident 29's enteral syringe was stored inside a clear plastic storage bag without the resident's name, date, and time. On 2/5/24 at 1304 hours, an observation and concurrent interview was conducted with LVN 14. LVN 14 verified Resident 29's enteral syringe was not labeled with the resident's name, date, and time. LVN 14 stated he used Resident 29's enteral syringe earlier in the morning when he administered Resident 29's morning medications via GT. LVN 14 stated the night shift licensed nurse were responsible to change the enteral syringe daily and label it with the residents' name and date. 2. On 2/4/24 at 1145 hours, an observation was conducted with Resident 110. Resident 110 was observed in bed with enteral feeding hanging and connecting to the enteral feeding pump. Resident 110's enteral syringe was stored inside a clear plastic storage bag without the resident's name, date, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 41 of 99 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 02/08/2024 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 0693 time. Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 110 was initiated on 2/4/24. Resident 110 was readmitted to the facility on [DATE]. Residents Affected - Few Review of Resident 110's H&P examination note dated 3/16/23, showed Resident 110 had dysphagia and enteral feeding. On 2/6/24 at 0825 hours, an observation was conducted with Resident 110. Resident 110 was observed in bed with enteral feeding and connecting to the enteral feeding pump. Resident 110's enteral syringe was stored a clear plastic storage bag labeled with the resident's name and date of 2/5/24. On 2/6/24 at 0829 hours, an observation and concurrent interview was conducted with LVN 11. LVN 11 verified Resident 110's enteral syringe was dated 2/5/24. LVN 11 stated the enteral syringe should be changed daily. LVN 11 was observed discarding the enteral syringe and placing an unopened and labeled enteral syringe on Resident 110's bedside table. On 2/6/24 at 1410 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the enteral syringes were changed every 24 hours by the night shift licensed nurses and should be labeled with the residents' name, date, and time when it was changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 42 of 99 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 02/08/2024 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 maintain the intravenous accesses for one of 33 final sampled residents (Resident 105) and one nonsampled resident (Resident 814). Residents Affected - Few * The facility failed to ensure Resident 105's midline catheter was assessed upon admission and weekly. In addition, Resident 105's midline catheter dressing was unlabeled and undated. * The facility failed to follow the physician's orders for flushing of the intravenous catheter before medication administration for Resident 814. These failures had the potential to delay identification of catheter related complications for the residents, an increased risk of potential drug incompatibility and lacking assessment of IV line patency prior to medication administration. Findings: According to Taylor's Fundamentals of Nursing, seventh edition, midline catheters are inserted peripherally, normally just above or below the antecubital fossa (located in the depression on the anterior surface of the elbow joint) into the proximal basilica or cephalic veins (basilic and cephalic veins begin their path from around the wrist and continue towards the area above the forearm). These catheters are longer than peripheral venous catheters, and the distal tip dwells in the basilic, cephalic, or brachial veins at or below the axillary level and distal to the shoulder. The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, under Catheter Site Dressing Regimens, showed to monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. 1. Medical record review for Resident 105 was conducted on 2/4/24. Resident 105 was admitted to the facility on [DATE]. Review of Resident 105's MDS dated [DATE], showed Resident 105 had a moderately impaired cognition. Review of the Order Summary Report showed the following physician's orders dated on: -12/27/23, to check blood return, and flush with 10 ml normal saline two times a day before and after medication administration; -12/27/23, to check blood return, and flush with 10 ml normal saline at least every 12 hours and as needed; -12/27/23, to monitor site complications every eight hours and notify the physician for complications; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 43 of 99 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 02/08/2024 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 0694 -12/27/23, may leave catheter in as long as site is free of complications, maximum of seven days; Level of Harm - Minimal harm or potential for actual harm -12/27/23, to discontinue IV when complete; and -1/30/24, to administer Vancomycin IV solution 1.2 grams intravenously two times a day. Residents Affected - Few Review of Resident 105's LN-Initial admission Record dated 1/23/24, did not show an assessment of the resident's midline catheter was documented upon admission. On 2/6/24 at 0901 hours, an observation and concurrent interview was conducted with Resident 105 with CNA 11 present. Resident 105 was observed with the double lumen intravenous catheter on his right arm. There was no date or label on the intravenous catheter dressing. A redness and scab was observed on the left lower edge of the intravenous catheter dressing. Resident 105 stated it started as itchy, then it became a blister about three days ago. On 2/6/24 at 1239 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated Resident 105 was admitted with the midline catheter. When asked about the assessment of Resident 105's midline catheter, RN 1 stated the RNs assessed the length of the catheter and the resident's arm circumference upon admission and weekly. RN 1 verified there was no documentation of the RNs' assessment of the length of the catheter and arm circumference for Resident 105. RN 1 also stated the RNs assessed the catheter site daily upon giving the IV medication and also changed the dressing weekly. RN 1 stated they were supposed to notify the physician such as redness, swelling, fever, and issues with the patency of the catheter. On 2/6/24 at 1302 hours, an observation for Resident 105 and concurrent interview was conducted with Resident 105 and RN 1. There was no date or label on the intravenous catheter dressing. A redness and scab were observed on the left lower edge of the intravenous catheter dressing. Resident 105 stated the skin irritation started three days ago. RN 1 verified there was no label or date on the IV catheter dressing. RN 1 stated she just noticed the redness and scab on the left lower edge of the dressing in the morning. RN 1 stated she notified the physician and informed the treatment nurse about it. 2. Review of Resident 814's medical record was initiated on 2/4/24. Resident 814 was admitted on [DATE]. Review of the Physician's Order Summary Report showed an order dated 1/22/24, to administer ceftriaxone sodium injection solution reconstituted 2 gm intravenously one time a day, to check blood return before and after medication administration, and flush with 10 ml of normal saline every shift. On 2/4/24 at 0934 hours, an observation of medication administration of 2 grams of ceftriaxone was conducted for Resident 814. Resident 814 was observed to have a two-lumen IV catheter on the right upper arm with the dressing dated 2/1/24. During the observation, RN 4 had prepared the antibiotic solution by attaching the powdered vial to a 100 ml bag of normal saline and reconstituted the medication. RN 4 primed the IV line and grabbed two 10 ml of prefilled normal saline syringes. RN 4 removed the cap of the IV hub of Resident 814 and cleaned with an alcohol swab and proceeded to check for blood return, then flushed the IV line with half (5 ml) of the 10 ml syringe into each lumen before medication administration. RN 4 flushed the lumens with 5 ml instead of 10 ml as ordered. On 2/4/24 at 1325 hours, RN 4 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 44 of 99 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 02/08/2024 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 0694 On 2/8/24 at 1158 at hours, the DON was informed of the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 45 of 99 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 02/08/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the initial facility tour on 2/4/24 at 0908 hours, Resident 107 was observed sitting in bed and receiving oxygen via nasal cannula at 4.5 lpm. A set-up bag was observed at bedside dated 1/31/24, and the humidifier connected to the oxygen concentrator was dated 1/31/24. Residents Affected - Few Medical record review for Resident 107 was initiated on 2/4/24. Resident 107 was readmitted to the facility on [DATE]. Review of Resident 107's MDS dated [DATE], showed Resident 107 was cognitively intact. Review of Resident 107's Order Summary Report failed to show a physician's order to administer oxygen. Further review of Resident 107's medical record review failed to show a physician's order was obtained prior to the use of oxygen. On 2/4/24 at 0911 hours, an observation for Resident 107 and concurrent interview and medical record review was conducted with LVN 12. LVN 12 verified the above finding. LVN 12 verified there was no physician's order obtained prior to the use of oxygen for Resident 12. 3. During the initial facility tour on 2/4/24 at 1112 hours, Resident 19 was observed in bed. A BiPap (bilevel positive airway pressure, or a non-invasive ventilation with a breathing support administered through a face mask, nasal mask, or a helmet to which the air, usually added with oxygen, is given through the mask under positive pressure) nasal mask was observed hanging on the wall. When asked about the BiPap, Resident 19 stated she used the BiPap machine every night. Medical record review for Resident 19 was initiated on 2/4/24. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's MDS dated [DATE], showed Resident 19 was cognitively intact. Review of Resident 19's Order Summary Report showed the following physician's orders: - Dated 12/30/22, to wash the BiPap humidified container with hot water and soap, and leave open to air to air dry every day shift every Sunday. - Dated 12/30/22, to wipe down BiPap mask visible residue with a wet washcloth and leave to air dry every day shift. - Dated 12/30/22, BiPap setting. - Dated 1/31/23, to place BiPap when resident naps or settings. However, there was no Bipap setting ordered by the physician. Review of Resident 19's plan of care showed a care plan problem initiated on 12/30/22, to address the use of BiPap during naps and sleep. The interventions showed to ensure the BiPap was set as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 46 of 99 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 02/08/2024 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 0695 ordered. Level of Harm - Minimal harm or potential for actual harm On 2/7/24 at 1351 hours, an interview was conducted with the DON. The DON verified the findings. The DON verified there were no BiPap settings indicated in the physician's order. The DON stated the BiPap was used by Resident 19 every night and cleaned by the licensed staff weekly. Residents Affected - Few On 2/7/24 at 1409 hours, an observation of Resident 19 and concurrent interview was conducted with the DON. The BiPap nasal mask was observed hanging on the wall. The DON verified the finding. The DON stated the BiPap nasal mask should be stored in the set-up bag after it had been air dried. 4. On 2/4/24 at 0912 and 1100 hours, Resident 662 was observed receiving oxygen at 5 lpm via nasal cannula. Medical record review for Resident 662 was initiated on 2/4/24. Resident 662 was admitted to the facility on [DATE]. Review of the Resident 662's Physician Order Summary dated 1/25/24 showed an order to administer oxygen at 4 lpm via nasal cannula continuously. However, during the above observation, Resident 662 was on oxygen at 5 lpm via nasal canula. On 2/4/24 at 1108 hours, an observation, interview, and concurrent medical record review for Resident 662 was conducted with the MDS Coordinator. The MDS Coordinator was informed of the above finding. The MDS Coordinator acknowledged Resident 662 was receiving oxygen at 5 lpm instead of 4 lpm as ordered by the physician. On 2/7/24 at 1617 hours, an interview was conducted with the DON. The DON verified and acknowledged the above finding. 5. On 2/6/24 at 1026 hours, Resident 134's nebulizer machine was observed on the floor underneath the resident's bedside table. On 2/6/24 at 1030 hours, an observation and concurrent interview was conducted with LVN 10. LVN 10 verified Resident 134's nebulizer machine was on the floor underneath the resident's bedside table. LVN 10 stated the nebulizer machine should be placed on top of the resident's bedside table. Medical record review for Resident 134 was initiated on 2/6/24. Resident 134 was admitted to the facility on [DATE]. Review of Resident 134's H&P examination dated 12/26/23, showed Resident 134 had the capacity to understand and make decisions. Review of Resident 134's Order Summary Report showed a physician's order dated 1/25/24, to administer budesonide (medication used to prevent difficulty breathing, chest tightness, wheezing and coughing) inhalation suspension 0.5 mg/2 ml inhale orally two times a day for shortness of breath for 14 days. The Order Summary Report also showed a physician's order dated 12/27/23, to administer ipratropium-albuterol (medication used to help relax and open the air passages to the lungs to make breathing easier) inhalation solution 3 mg/3 ml inhale orally every four times a day for bronchodilator. On 2/6/24 at 1410 hours, an interview was conducted with the DON. The DON was informed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 47 of 99 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 02/08/2024 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 0695 acknowledged the above finding. Level of Harm - Minimal harm or potential for actual harm 6. During the initial tour of the facility on 2/4/24 at 1040 hours, Resident 156's nebulizer mask and tubing were observed with the date of 1/17/24. Residents Affected - Few Medical record review for Resident 156 was initiated on 2/4/24. Resident 156 was admitted to the facility on [DATE]. Review of Resident 156's Order Summary Report showed a physician's order dated 12/27/23, to administer albuterol sulfate (used to help open the airways to make breathing easier) nebulization solution 2.5 mg/3 ml inhale orally via nebulizer every six hours as needed for shortness of breath. On 2/4/24 at 1104 hours, an observation and concurrent interview was conducted with LVN 13. LVN 13 verified Resident 156's nebulizer mask and tubing were dated 1/17/24. LVN 13 stated she was from a registry company and was not oriented by the facility on how often the nebulizer equipment should be changed. 7. On 2/4/24 at 1031 hours and 2/5/24 at 1300 hours, Resident 29 was observed wearing a nasal cannula attached to an oxygen concentrator with a setting of 3 lpm. Resident 29's oxygen nasal cannula tubing was observed undated. Medical record review for Resident 29 was initiated on 2/4/24. Resident 29 was readmitted to the facility on [DATE]. Review of Resident 29's Order Summary Report showed a physician's order dated 2/4/24, to administer supplemental oxygen at 2 to 4 lpm via nasal cannula as needed to keep SP02 (oxygen saturation) level greater than 92%. On 2/5/24 at 1304 hours, an observation and concurrent interview was conducted with LVN 14. LVN 14 verified Resident 29's oxygen cannula tubing was undated. LVN 14 stated oxygen cannula tubing are changed every Wednesday by the central supply staff. However, LVN 14 stated the licensed nurses were responsible to ensure oxygen cannula tubing were dated. 8.a. Review of the facility's P&P titled Medication Administration- General Guidelines revised 10/2019 showed medications are administered as prescribed in accordance with good nursing principle and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy also showed medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. On 2/4/24 at 1330 hours, Resident 110 was observed receiving nebulizer treatment via nebulizer mask with the caregiver at bedside. OT 2 was observed at bedside providing therapy. The caregiver then, turned off the nebulizer machine. The caregiver stated LVN 16 instructed her to turn off the nebulizer machine when the medication was done. OT 2 verified the caregiver's statement and stated LVN 16 also instructed her to turn off the nebulizer machine when the medication was done. Medical record review for Resident 110 was initiated on 2/4/24. Resident 110 was readmitted 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 48 of 99 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 02/08/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 110's Order Summary Report showed a physician's order dated 1/11/24, to administer ipratropium-albuterol inhalation solution 3 mg/3 ml inhale orally every four times a day for shortness of breath and wheezing. Review of Resident 110's MAR for February 2024 showed Resident 110 was administered ipratropium-albuterol inhalation solution on 2/4/24 at 1300 hours. On 2/4/23 at 1335 hours, an observation and concurrent interview was conducted with LVN 16. LVN 16 was informed of the above finding. LVN 16 stated other facility staff were allowed to turn off the nebulizer machine after the medication was administered. When asked if the caregiver was allowed to turn off the nebulizer machine, LVN 16 stated, no. LVN 16 stated she told OT 2 to turn off the nebulizer machine when the medication was done because OT 2 was working with Resident 110. b. On 2/7/24 at 0804 hours, Resident 110 was observed in bed. Resident 110's nebulizer mask was observed on the bedside table uncovered. Review of Resident 110's Order Summary Report showed the following physician's orders: - Dated 10/25/24, to administer acetylcysteine (used to thin out mucus so it may be coughed up) inhalation solution 10% four ml inhale orally every 12 hours for mucus secretion, - Dated 1/11/24, to administer ipratropium-albuterol inhalation solution 3 mg/3 ml inhale orally every four times a day for shortness of breath and wheezing, and - Dated 1/11/24, to administer ipratropium-albuterol inhalation solution 3 mg/3 ml inhale orally every six hours as needed for shortness of breath and wheezing. On 2/7/24 at 0829 hours, an observation and concurrent interview was conducted with LVN 11. LVN 11 verified the above finding. LVN 11 stated the nebulizer mask should be stored inside a plastic setup bag in between uses. On 2/7/24 at 0836 hours, an interview was conducted with the DON. When asked if caregivers and/or other facility staff besides licensed nurses were allowed to turn off the nebulizer machine once the nebulizer treatment was completed, the DON stated, no, even OT are not allowed. The DON stated turning on and off the nebulizer machine was considered medication administration and only the licensed nurses were allowed to do so. 9. On 2/4/24 at 1238 hours and 2/5/24 at 1240 hours, Resident 762's CPAP nose piece and tubing was observed on the dresser uncovered. Resident 762 stated he used the CPAP every night and the facility staff would usually leave the nose piece and tubing on the dresser uncovered. Medical record review for Resident 762 was initiated on 2/4/24. Resident 762 was admitted to the facility on [DATE]. Review of Resident 762's Order Summary Report dated 2/5/24, showed a physician's order dated 1/26/24, to use CPAP from home with the same settings at bedtime (from 2200 hours to 0600 hours per the resident's preference) for sleep apnea. On 2/5/24 at 1245 hours, an observation and concurrent interview was conducted with LVN 14. LVN 14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 49 of 99 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 02/08/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few verified Resident 762's CPAP nose piece and tubing was on the dresser uncovered. LVN 14 stated the CPAP nose piece and tubing should be stored inside a plastic storage bag in between uses. On 2/6/24 at 0952 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding. The DON stated licensed nurses were expected to rinse and air dry the nose piece and store inside a plastic storage bag. 10. Medical record review for Resident 100 was initiated on 2/4/24. Resident 100 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of the H&P examination dated 1/1/24, showed the resident had the capacity to understand and make decisions. Review of the Order Summary Report for month of February 2024 showed a physician's order dated 1/2/24, as follows: - Apply CPAP any time after 2000 hours nightly with the resident's assistance. The resident may connect and apply to self nightly without assistance every evening and night shift. - For CPAP humidified container, to wash with hot water and soap, leave open to air every day shift every Sunday. - For CPAP mask: to wipe down visible residue with a wet washcloth and leave open to air dry every day shift. During the initial tour of the facility On 2/4/24 at 0950 hours, an observation and concurrent interview was conducted with Resident 100. Resident 100 stated the CPAP mask and tubing were not being cleaned routinely. The CPAP was observed stored in an unlabeled bag. Resident 100 further stated the mask did not fit her which awakens her at night. On 2/4/24 at 1038 hours, an observation and concurrent interview was conducted with LVN 9. LVN 9 verified the CPAP was inside an unlabeled bag. LVN 9 stated the tubing should be changed once a week and the bag should be labeled with a date. On 2/7/24 at 0911 hours, an interview was conducted with the DON. The DON stated she would expect the CPAP mask should be cleansed daily, tubing should be washed once a week, and stored in a bag changed weekly. The DON was informed and acknowledged the above findings. The DON further stated she would follow up to ensure Resident 100 had a mask that would fit her. 11. Medical record review for Resident 162 was initiated on 2/4/24. Resident 162 was admitted on [DATE], and readmitted to the facility on [DATE]. Review of the H&P examination dated 1/13/24, showed the resident had the capacity to make needs known and make own decisions. Review of the Order Summary Report for month of February 2024 showed the physician's orders dated 1/28/24, as follows: - Apply BiPAP at night and PRN with home settings every night shift. The resident may connect and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 50 of 99 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 02/08/2024 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 0695 apply to self nightly without assistance every evening and night shift. Level of Harm - Minimal harm or potential for actual harm - For BiPAP humidified container, to wash with warm water and soap and allow to air dry weekly every day shift every Sunday. Residents Affected - Few - For BiPAP Mask or nasal pillow, to wash with warm water and soap and allow to air dry daily every weekly every day shift every Sunday. - For BiPAP Mask or nasal pillow, to wipe down visible residue with a wet washcloth and leave open to air dry every day shift. - For BiPAP tubing, to rinse with water and allow to air dry daily every day shift, and to wash with warm water and soap and allow to air dry. - For BiPAP tubing, to wash with warm water and soap and allow to air dry daily every weekly every day shift every Sunday. During the initial tour of the facility on 2/4/24 at 1017 hours, Resident 162's BiPAP mask and tubing was observed in the top drawer of the night stand, opened, and exposed to air. There was a bag hanging at the night stand dated 1/10/24. Resident 162 stated the BiPAP mask and tubing were not being cleaned routinely. On 2/4/24 at 1038 hours, an observation and concurrent interview was conducted with LVN 9. LVN 9 verified the BiPAP mask and tubing was inside the top drawer of the night stand opened and exposed to air. LVN 9 also verified the bag hanging at the night stand was dated 1/10/24. LVN 9 stated the tubing should be changed once a week and stored in a bag labeled with a date. On 2/7/24 at 0911 hours, an interview was conducted with the DON. The DON stated she expected the BiPAP mask should be cleansed daily, tubing should be washed once a week, and stored in a bag changed weekly. The DON was informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of 33 final sampled residents (Residents 19, 29, 61, 107, 110, and 128) and six nonsampled residents (100, 134, 156, 162, 662, and 762). This failure posed the risk for residents' safety and respiratory related complications including infection. * The facility failed to obtain the physician's order for oxygen therapy for Residents 107 and 128. * The facility failed to ensure Resident 19's BiPap was stored properly and not hanging on the wall. * The facility failed to provide oxygen therapy as per the physician's order for Resident 662. * The faclity failed to ensure the nebulizer machine was not on the floor for Resident 134. * The facility failed to ensure the nebulizer mask and tubing were changed weekly and dated for Residents 29 and 156. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 51 of 99 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 02/08/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure the CPAP was being cleaned, the set up bag was dated, and the CPAP mask with tubing was not exposed to air for Resident 100. * The facility failed to ensure the nebulizer mask and tubing were stored in a set up bag for Residents 61, 162, 110, and 762. Residents Affected - Few * The facility failed to ensure the BiPAP mask and tubing were routinely cleaned and stored in the set-up bag when not in use for Resident 162. These failures had the potential to negatively impact the residents and posed the risk for respiratory complications. Findings: Review of the facility's P&P titled Medical Equipment, Storage, Labeling, Cleaning and Disinfecting revised 5/2020 showed to change nebulizer mask, mouthpiece tubings once a week and as needed. In addition, the policy showed to store handheld nebulizer in plastic provided after each use. Review of the facility's P&P titled Resident Care, Oxygen, Use of revised 5/2021 showed tubing, masks, humidifiers, and other disposable used for oxygen administration will be dated in an identifiable fashion. Review of the facility's undated P&P titled CPAP showed fit the resident with proper size face or nasal CPAP mask utilizing the sizing gauge (small, medium, or large). For cleaning and maintenance wipe down any visible residue on mask or nasal pillow with wet wash cloth and leave to air dry. When the mask or nasal pillow is dry, reassemble according to the reassembly instructions. Do not use disinfectant. Handwash the tubing every week with warm water and soap and allow to air dry. Tubing is to be changed as needed. Review of the facility's undated P&P titled BiPAP's and CPAP showed for cleaning and maintenance, wipe down any visible residue on mask or nasal pillow with wet wash cloth and leave to air dry. When the mask or nasal pillow is dry, reassemble according to the reassembly instructions. Do not use disinfectant. Handwash the tubing every week with warm water and soap and allow to air dry. Tubing is to be changed as needed. Review of the facility's P&P titled Oxygen Administration reviewed 10/11/23, showed a physician's order must be obtained prior to oxygen therapy initiation and staff to follow the facility protocol for safe oxygen administration practice. 1. On 2/4/24 at 0930 hours, Resident 128 was observed lying in bed and receiving oxygen via nasal cannula at the rate of 4.5 lpm. Resident 128 stated he had been receiving oxygen therapy since he was admitted to the facility on [DATE]. Resident 128 pressed on the call light for assistance as the oxygen concentrator started to sound an alarm. LVN 2 came and replaced the distilled water as it was running low. Medical record review for Resident 128 was initiated on 2/4/24. Resident 128 was admitted to the facility on [DATE]. Review of Resident 128's Progress Note dated 2/4/24, showed the medical history of chronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 52 of 99 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 02/08/2024 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 0695 hypoxemic respiratory failure. Level of Harm - Minimal harm or potential for actual harm Review of the Order Summary Report dated 2/4/24, failed to show a physician's order for oxygen therapy. Residents Affected - Few Review of the resident' Daily Skilled/Condition Monitoring dated 1/8 to 2/4/24, showed daily monitoring of oxygen saturation level with method of oxygen delivery via nasal cannula. Review of the Progress Note dated 2/4/24, at 1519 hours, showed a documentation entered by LVN 8 Spoke with MD regarding oxygen order. Agrees to have a continuous oxygen order via NC at 2 lpm for hypoxia. Will continue to monitor. On 2/5/24 at 0845 hours, Resident 128 was observed lying in bed and receiving oxygen therapy at 2 L/min via nasal cannula. On 2/5/24 at 1245 hours, an interview was conducted with LVN 8. LVN 8 stated Resident 128 had been receiving oxygen continuously; however, there was no physician's order in the system prior. LVN 8 further stated he was able to contact the physician to obtain an order for continuous oxygen via nasal cannula at 2 lpm due to hypoxia yesterday afternoon. On 2/6/24 at 1405 hours, an interview was conducted with RN 1. RN 1 verified the physician's order and care plan should be in place for all residents who required oxygen use. 11. Medical record review for Resident 61 was initiated on 2/4/24. Resident 61 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 61's Order Summary Report dated 2/8/24, showed a physician's order dated 5/4/23, for arformoterol tartrate inhalation nebulization solution (medication used as maintenance treatment of air flow blockage in residents with COPD) 15 mcg/2 ml one vial inhale via nebulizer every 12 hours for congestion. On 2/4/24 at 0850 hours, during the initial tour of the facility, Resident 61's nebulizer mask and tubing attached to the nebulizer machine was observed on the nebulizer machine, unbagged, and exposed to air at the bedside table. An empty plastic bag was observed next to Resident 61's bed dated 1/31/24. On 2/4/24 at 0850 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the findings and stated the nebulizer mask and tubing should have been stored in the plastic bag next to Resident 61's bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 53 of 99 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 02/08/2024 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 observation, interview, and medical record review, the facility failed to offer or provide adequate and appropriate pain management for one of 33 final sampled residents (Resident 34). Residents Affected - Few * The facility failed to administer pain medication for Resident 34 after a fall on 1/26/24. This failure had the potential to cause the resident unnecessary pain and complications from worsened pain. Findings: On 2/4/24 at 1343 hours, during the initial tour of the facility, an interview was conducted with Resident 34. Resident 34 stated she had not been administered pain medication when she had a fall. When asked to elaborate, Resident 34 stated she had a horrible pain on her left ankle from a slow fall about two weeks ago. Resident 34 stated she was okay now, but it had a psychological effect on her, and she did not want to see the CNA who was assigned to her again. Medical record review for Resident 34 was initiated on 2/4/24. Resident 34 was readmitted to the facility on [DATE]. Review of Resident 34's MDS dated [DATE], showed Resident 34 was cognitively intact. Review of the eInteract Change in Condition Evaluation V4.2 dated 1/26/24, showed Resident 34 had a fall on 1/26/24, in the morning. Under the Pain Evaluation section showed Resident 34 had an acute pain on the left ankle, with a pain of 4, and was described as resident had pain in this area before fall that worsened after the fall. The evaluation form showed the physician was notified on 1/26/24 at 0400 hours, with pending response. Review of Resident 34's Order Summary Report showed the following physician's orders dated: - On 8/13/21, to monitor pain level using the following scale: 0= no pain, one to three = mild, four to six = moderate, and seven to ten = severe pain every shift; - On 8/13/21, for non-pharmacological interventions for pain 1 = repositioning, 2 = dim light/ quiet environment, 3 = relaxation, 4 = distraction, 5 = music, and 6 = massage as needed; - On 8/13/21, to apply lidocaine-prilocaine cream (topical anesthetic medication) 2.5 - 2.5% to the left leg topically every hours as needed for pain; - On 9/5/21, to document non-pharmacological interventions done every shift: 0= back rub, 1 = redirection, 2 = speak to/ approach in a calm manner, 3 = reposition, 4 = offer snacks/ fluid/ milk, 5 = assess for pain, 6 = provide a quiet environment, 7 = encourage to express feelings, 8 = take to activities, and 9 = provide reassurance as needed for complaint of pain before use of acetaminophen 325 mg two tablets; - On 9/7/21, to administer acetaminophen (over the counter pain medication) 325 mg two tablets by mouth every four hours as needed for mild pain one to three pain scale; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 54 of 99 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 02/08/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - On 1/25/22, to apply lidocaine cream (local anesthetic medication) 5 % to the left lateral ankle topically every eight hours as needed for pain - On 9/20/22, to apply diclofenac sodium cream (a nonsteroidal anti-inflammatory drug used for the treatment of pain, fever, and inflammation) 3 % to the left foot ankle topically two times a day two times a day; and - On 11/30/23, to administer meloxicam (a nonsteroidal anti-inflammatory drug used for the treatment of pain) 15 mg one tablet by mouth as needed for pain management once a day. Review of Resident 34's MAR for January 2024 showed Resident 34 received the meloxicam medication on 1/26/24 at 0900 and 2100 hours. The record did not show Resident 34 was provided non-pharmacological interventions, and/or pain medication on 1/26/24, to address Resident 34's left ankle pain after the fall. Further review of Resident 34's medical record did not show a documented evidence non-pharmacological interventions or pain medication were administered to Resident 34 to address the resident's left ankle pain after the fall on 1/26/24. On 2/7/24 at 0921 hours, an interview and concurrent medical record review for Resident 34 was conducted with the MDS Coordinator. The MDS Coordinator verified the findings. The MDS Coordinator verified Resident 34 was not provided non-pharmacological interventions and was not administered pain medication for the resident's left ankle pain from the fall on 1/26/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 55 of 99 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 02/08/2024 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 0698 Provide safe, appropriate dialysis care/services 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** 3. Medical record review for Resident 107 was initiated on 2/4/24. Resident 107 was readmitted to the facility on [DATE], with a diagnosis of end stage renal disease requiring hemodialysis treatment. Residents Affected - Few Review of Resident 107's Order Summary Report showed the following physician's orders dated: - On 9/27/23, to assess dialysis site: left upper arm AV fistula for bruit and thrill every shift. Document (+) or (-), call MD for absence. - On 9/27/23, to assess shunt/ dialysis site: left arm fistula every shift and document C = clear, T = tenderness, R = redness, or B = bleeding every shift. - On 9/27/23, to monitor AV shunt site (left arm fistula) for redness, bleeding, skin breakdown, and edema every shift. - On 9/27/23, to check dialysis site post-dialysis: left upper arm AV fistula for bleeding every shift and remove pressure dressing after three hours. - On 10/4/23, to provide 1200 ml fluid restriction daily as follows: dietary total of 720 cc (breakfast 240 cc, lunch 240 cc, and dinner 240 cc); and nursing total of 480 cc (200 cc for nursing from 0700 to 1500 shift, 200 cc for nursing from 1500 to 2300 hours, and 80 cc for nursing from 2300 to 0700 hours). a. Review of Resident 107's Facility/ Dialysis Nursing Communication Record showed missing documentation of the pre and post-dialysis assessments and weights. For example: - On 12/24/23, the facility nurse/pre-dialysis section failed to show documented evidence the access site was assessed. In addition, a bleeding at the dialysis site was noted; however, there was no action documented in the post-dialysis section. - On 12/31/23, the facility nurse/pre-dialysis section was left blank. In addition, there was no pre and post-treatment weights documented by the dialysis nurse. Furthermore, a bleeding at the dialysis site was noted; however, there was no action documented in the post-dialysis section. - On 1/5/24, there were no pre and post-treatment weights documented by the dialysis nurse. In addition, the facility nurse/post-dialysis section was left blank - On 1/10/24, there was no documentation of the post-treatment weight by the dialysis nurse - On 1/19, and 1/24/24, the facility nurse/post-dialysis section was left blank - On 1/31/24, the facility nurse/post-dialysis section was incomplete, only the blood pressure and heart rate were documented - On 2/2/24, there were no pre and post-treatment weights documented by the dialysis nurse. b. Review of Resident 107's MAR for January and February 2024 showed the resident's intake exceeded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 56 of 99 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 02/08/2024 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 0698 the prescribed nursing fluid intake of 480 ml. For example: Level of Harm - Minimal harm or potential for actual harm - On 1/1, 1/19, 1/25, and 1/30/24, Resident 107 had a total of 1200 ml of fluid intake. - On 1/2/24, Resident 107 had a total of 910 ml of fluid intake. Residents Affected - Few - On 1/3, 1/10, 1/15, 1/19, 1/20, and 1/22/24, Resident 107 had a total of 860 ml of fluid intake. - On 1/4, 1/7, 1/14, 1/21, 1/27, 1/28 and 2/3/24, Resident 107 had a total of 920 ml of fluid intake. - On 1/5/24, Resident 107 had a total of 510 ml of fluid intake. - On 1/8/24, Resident 107 had a total of 960 ml of fluid intake. - On 1/9 and 1/17/24, Resident 107 had a total of 961 ml of fluid intake. - On 1/11 and 1/12/24, Resident 107 had a total of 750 ml of fluid intake. - On 1/13/24, Resident 107 had a total of 1120 ml of fluid intake. - On 1/16/24, Resident 107 had a total of 820 ml of fluid intake. - On 1/24/24, Resident 107 had a total of 560 ml of fluid intake. - On 1/26/24, Resident 107 had a total of 850 ml of fluid intake. - On 1/31/24, Resident 107 had a total of 1180 ml of fluid intake. - On 2/2/24, Resident 107 had a total of 780 ml of fluid intake. c. Review of the Documentation Survey Report v2 for January and February 2024 showed Resident 107 exceeded the prescribed dietary fluid intake of 720 ml. For example: - On 1/8/24, Resident 107 had a total of 800 ml of fluid intake. - On 1/9 and 1/29/24, Resident 107 had a total of 840 ml of fluid intake. - On 1/27/24, Resident 107 had a total of 1190 ml of fluid intake. - On 1/8/24, Resident 107 had a total of 800 ml of fluid intake. - On 1/30/24, Resident 107 had a total of 1040 ml of fluid intake. On 2/7/24 at 1310 hours, an interview and concurrent medical record for Resident 107 was conducted with the DON. The DON verified the above findings. The DON verified there was no physician's order for Resident 107's dialysis. The DON verified also the pre and post-dialysis assessments and weights were not documented. The DON verified the MAR and Documentation Survey Reports showed Resident 107 exceeded her nursing and dietary fluid intakes. The DON stated the Documentation Survey Report form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 57 of 99 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 02/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was the form used by the CNA to document Resident 107's dietary fluid intake. The DON stated the CNAs were supposed to report to the charge nurses the resident's fluid intake. The DON stated the licensed nurses would then add the nursing fluid intake and document the resident's total fluid intake in the MAR. 4. Medical record review for Resident 42 was initiated on 2/4/24. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's History and Physical examination note dated 2/5/23, showed Resident 42 had diagnosis of End Stage Renal Disease and was on hemodialysis. Review of Resident 42's Facility/Dialysis Center Nursing Communication Record forms for November 2023 showed the Facility/Dialysis Center Nursing Communication Record forms on 11/3, 11/10, and 11/13/23 were not in Resident 42's medical record. Review of Resident 42's Facility/Dialysis Center Nursing Communication Record forms for December 2023 showed the Facility Nurse Post-Dialysis section was left blank on 12/15 and 12/24/23. Review of Resident 42's Facility/Dialysis Center Nursing Communication Record forms for January 2024 showed the following: - The Facility Nurse Post-Dialysis section was left blank on 1/29 and 1/31/24, - The Dialysis Nurse section for signature and date was left blank on 1/26/24, - The Facility Nurse Post-Dialysis section for signature and date was left blank on 1/5 and 1/15/24, and - The Facility/Dialysis Center Nursing Communication Record form was left blank on 1/12/24. Further review of Resident 42's medical record failed to show documented evidence Resident 42 left and returned to the facility for hemodialysis on 11/3, 11/10, 11/13 and 1/12/24. In addition, review of Resident 42's medical record failed to show documented evidence the scheduled hemodialysis on 11/10/23, was rescheduled due to the holiday. On 2/8/24 at 0903 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for four of 33 final sampled residents (Residents 42, 107, 128, and 812) who required dialysis. * The facility failed to ensure Residents 812's pre dialysis assessment (access site, vital signs, time of last meal, blood sugar, lung sound assessment, LOC, Covid-19 signs, and symptoms), dialysis center assessment and post dialysis assessment (dressing in place, bleeding on site, SOB, assessment of dialysis site, signs and symptoms of infection to access site, vital signs, and Covid-19 signs and symptoms) were completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 58 of 99 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 02/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few * The facility failed to perform the post dialysis treatment assessment and ensure the dialysis communication forms for Resident 128 were completed. * The facility failed to consistently monitor Resident 107's weight and dialysis access site for pre and post-dialysis. In addition, the facility failed to implement and monitor the fluid intake and output for Resident 107 as per the physician's order. The licensed nurses and CNAs' documentation of Resident 107's intake and output were inaccurate. * The facility failed to ensure the facility and dialysis center communication forms were completed for Resident 42. These failures had the potential risk for Residents 812, 128, 107 and 42 not being provided the appropriate care and treatment, which could lead to medical complications. Findings: Review of the facility's P&P titled Dialysis (Renal), Pre and Post Care revised on December 2023 showed it is the policy of the facility to: - Assist resident in maintaining homeostasis pre and post renal dialysis - Assess and maintain patency of the renal dialysis access - Assess resident daily function related to renal dialysis - Participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Documentation related to pre- and post-dialysis care will be placed in the clinical record and include the following: a. Resident assessments, interventions, and any provided education. b. Assessment of renal dialysis access site, to include presence or absence and quality care of a bruit and thrill (a thrill or buzz is like a vibration caused by blood flowing through the fistula and can be felt by placing fingers just above the access site. A bruit is a whooshing sound heard upon listening near the fistula site using a stethoscope) for residents with an arteriovenous fistula (a connection that's made between an artery and a vein for dialysis access). c. Communication between the facility and dialysis staff or medical provider. 1. Medical record review for Resident 812 was initiated on 2/5/24. Resident 812 was admitted [DATE]. Review of Resident 812's Order Summary Report for February 2024 showed a physician's order dated 2/2/24, to arrange hemodialysis every Tuesday, Thursday, and Saturday at the dialysis center. On 2/6/24 at 0902 hours, an interview was conducted with LVN 6. LVN 6 stated Resident 812 went out to dialysis this morning. LVN 6 stated the resident's pre-assessment was completed and the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 59 of 99 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 02/08/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm dialysis center communication form was taken by the resident to the dialysis center for communication of care. Review of Resident 812's facility and dialysis center nursing communication record forms showed the following: Residents Affected - Few - The pre-dialysis assessment on 2/1/24, was incomplete. - The facility nurse/pre-dialysis assessment on 2/3/24, was not completed by the nurse from the dialysis center. - The post-dialysis assessments on 2/1 and 2/3/24, were incomplete. - The facility nurse/post dialysis assessment on 2/6/24, was not completed by the dialysis center nurse. On 2/6/24 at 1349 hours, interview and concurrent medical record review was conducted with LVN 6. LVN 6 was informed and acknowledged the findings. On 2/7/24 at 0935 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings. 2. On 2/6/24 at 0940 hours, review of Resident 128's medical record was conducted. The Progress Note dated 2/6/24, showed Resident 128 had a history of End Stage Renal Disease receiving hemodialysis 3 times a week (Monday, Wednesday, and Friday). On 2/6/24 at 0950 hours, review of Resident 128's Facility/Dialysis Center Nursing Communication Record forms showed the following: - no assessment for post dialysis treatment dated on 1/10/24, - missing the post treatment weight on 1/22 and 1/29/24, - missing the signature of licensed nurse for the post dialysis assessment dated [DATE]. In addition, the location of dialysis written on the communication form was not the location of the Dialysis Center where the resident actually received the dialysis treatment. On 2/6/24 at 1020 hours, an interview was conducted with LVN 8. LVN 8 stated upon return from the dialysis, a post assessment should be done to ensure the resident was safe. He further confirmed the dialysis communication forms were to be completed with every dialysis treatment for continuation of care. On 2/7/24 at 1142 hours, an interview was conducted with RN 1. RN 1 verbalized the nurse should assess the resident upon their return from dialysis to ensure the resident's safety and free from dialysis complications. She would also communicate with the nurses to confirm the correct dialysis location was written on the communication form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 60 of 99 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 02/08/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **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 for two of 33 final sampled residents (Residents 12 and 89). * The facility failed to obtain the consent for 1/2 side rails for Resident 12 as per the physician's order. In addition, the facility failed to ensure the bed assessment was correct to reflect Resident 12's bariatric bed. These failures had the potential to put the residents at risk for serious injuries from side rail use. Findings: Review of the facility's P&P titled Bed Rails revised 12/2023 showed the following: - After the facility has attempted alternatives to bedrails and determined that these alternatives failed to meet the resident's assessed needs, the facility IDT will assess the resident for risks of entrapment. The risks and benefits regarding the use of bed rails will be considered for each resident; - If the use of bedrails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use; and - The facility should maintain evidence that it has provided sufficient information prior to installation so the resident or resident representative could make an informed decision. Information that the facility must provide to the resident, or resident representative includes, but are not limited to: a. What assessed medical need(s) would be addressed by the use of side rails; b. The resident's benefits from the use of bedrails and the likelihood of these benefits; c. The resident's risks from the use of bed rails and how these risks will be mitigated; and d. Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate. On 2/4/24 at 1017 hours, 2/5/24 at 1215 hours, and 2/6/24 at 0918 hours, Resident 12 was observed in a bariatric bed with bilateral ½ (half) side rails elevated. Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 was cognitively intact and required partial/moderate assistance of one staff for bed mobility and transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 61 of 99 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 02/08/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 12's Order Summary Report showed a physician's order dated 9/15/21, for bariatric bed with bilateral ½ side rails as enabler for turning and repositioning. Review of the Facility Verification of Informed Consent dated 7/22/19, showed the consent was for the use ¼ (quarter) side rails on both sides of the bed for positioning. The consent form did not reflect the physician's order for ½ side rails. Review of the Bed Rail Safety Evaluation Form dated 2/1/24, under Equipment Factors section, showed Resident 12 had a standard type of bed in use. The evaluation form was inconsistent with the physician's order for a bariatric bed and the actual bed that Resident 12 was using. On 2/4/24 at 1017 hours, an observation and concurrent interview was conducted with Resident 12. Resident 12 was observed in a bariatric bed with bilateral side rails elevated. Resident 12 stated she had the bilateral rails for a long time and she also signed for it a long time ago. On 2/7/24 at 1250 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON verified the above findings. The DON verified the consent form did not reflect the physician's order for ½ side rails. The DON also verified the evaluation form was inconsistent with the physician's order for a bariatric bed, and the actual bed Resident 12 was using. Cross reference to F909, example #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 62 of 99 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 02/08/2024 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 meet the residents' needs for two of 33 final sampled residents (Residents 24 and 42) and two nonsampled residents (Residents 162 and 814). In addition, the facility failed to ensure the controlled medication was accurately reconciled. * The facility failed to ensure Residents 24 and 42's scheduled medications were administered within 60 minutes of scheduled time per the facility's P&P. * The facility failed to ensure accurate documentation of the controlled medications to one nonsampled resident (Resident 162) for hydrocodone-acetaminophen 5-325 mg (narcotic pain medication). * The facility failed to ensure the prefilled normal saline syringe for Resident 814 was not left unattended on the medication cart. These failures had the potential to negatively affect the residents' health and drug diversion. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines revised 10/2019 showed medications are administered within 60 minutes of scheduled time, except before and after meals orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medications administration schedule for the facility. 1. During the initial tour of the facility on 2/4/24 at 1154 hours, an interview was conducted with Resident 24. Resident 24 stated she had not gotten her morning medications. Resident 24 stated her medications were usually given late on the weekends when the licensed nurses from a registry company were scheduled. On 2/4/24 at 1202 hours, LVN 13 was observed entering Resident 24's room. Resident 24 was observed asking LVN 13 for her morning medications. LVN 13 then answered she would come back with Resident 24's medications. Medical record review for Resident 24 was initiated on 2/4/24. Resident 24 was readmitted to the facility on [DATE]. Review of Resident 24's H&P examination dated 10/3/23, showed Resident 24 had the capacity to make decisions for herself. Review of Resident 24's Order Summary Report dated 2/7/24, showed the following physician's orders: - dated 6/82/23, to administer insulin regular human (use to treat high blood sugar) injection solution per sliding scale subcutaneously before meals and at bedtime, - dated 6/82/23, to administer pregabalin (use to treat nerve pain) oral capsule 25 mg by mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 63 of 99 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 02/08/2024 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 every eight hours, Level of Harm - Minimal harm or potential for actual harm - dated 6/82/23, to administer simethicone (use to reduce bloating and pain caused by excessive gas) oral tablet 80 mg by mouth every eight hours, Residents Affected - Few - dated 10/2/23, to administer Brilinta (blood thinner use to prevent stroke and other heart problems) oral tablet 90 mg by mouth one time a day, - dated 10/2/23, to administer carvedilol (use to treat high blood pressure) oral tablet 6.25 mg by mouth two times a day, - dated 10/2/23, to administer guaifenesin (cough medication) oral liquid 200 mg/5 ml by mouth one time a day, - dated 10/2/23, to administer hydralazine HCl (use to treat high blood pressure) oral tablet 25 mg give three tablets by mouth three times a day, - dated 10/2/23, to administer isosorbide mononitrate (use to prevent chest pain) ER (extended release) tablet 30 mg by mouth one time a day, - dated 10/2/23, to administer linagliptin (use to help control blood sugar) oral tablet 5 mg by mouth one time a day, - dated 10/2/23, to administer losartan potassium (use to treat high blood pressure) oral tablet 50 mg by mouth one time a day, - dated 10/22/23, to administer pantoprazole sodium (use to help decrease the amount of acid the stomach makes) oral tablet delayed release 40 mg by mouth in the morning, - dated 10/22/23, to administer Synthroid (use to treat underactive thyroid) oral tablet 70 mcg by mouth in the morning, administer with full glass of water on empty stomach, 30-60 minutes before breakfast, and - dated 1/19/24, to administer Paxlovid (use to treat mild to moderate COVID-19 symptoms) oral tablet 150/100 mg by mouth two times a day. Review of Resident 24's Medication Admin Audit Report dated 2/5/24, showed the following late medication administrations: - on 2/3/24, the 0600 hours doses for pregabalin and simethicone were administered at 0824 hours. - on 2/3/24, the 0630 hours dose for insulin regular human injection solution was administered at 0824 hours, and 0630 hours doses for Synthroid and pantoprazole were administered at 0825 hours. - on 2/4/24, the 0800 hours doses for guaifenesin, Brilinta, hydralazine, and losartan potassium were administered at 1243 hours. - on 2/4/24, the 0900 hours doses for Paxlovid, isosorbide mononitrate ER, linagliptin, and carvedilol were administered at 1243 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 64 of 99 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 02/08/2024 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 - on 2/4/24, the 1200 hours dose for hydralazine oral tablet was administered at 1502 hours. Level of Harm - Minimal harm or potential for actual harm 2. On 2/4/24 at 1148 hours, Resident 42 was observed sitting on her wheelchair by her bed. Resident 42 stated she was waiting for her family member to visit. Residents Affected - Few On 2/4/24 at 1208 hours, LVN 13 was observed entering Resident 42's room and telling Resident 42 that she was going to check her blood pressure and blood sugar level. On 2/4/24 at 1214 hours, LVN 13 was observed administering the medication to Resident 42. Medical record review for Resident 42 was initiated on 2/4/24. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's MDS dated [DATE], showed Resident 42's had moderate cognitive impairment. Review of Resident 24's Order Summary Report dated 2/8/24, showed the following physician's orders: - dated 8/11/21, to administer famotidine (use to treat conditions that cause excess stomach acid) oral tablet 20 mg by mouth two times a day; - dated 8/31/21, to administer dorzolamide HCl-timolol (use to treat increased pressure in the eye) ophthalmic solution 2-0.5% instill one drop in the right eye two times a day; - dated 9/7/21, to administer [NAME]-Vite (use to treat or prevent vitamin deficiency, designed for dialysis residents) oral tablet by mouth one time a day; - dated 10/24/21, to administer amlodipine besylate (use to treat high blood pressure) oral tablet 10 mg by mouth one time a day; - dated 1/20/22, to administer docusate sodium (stool softener) oral capsule 100 mg by mouth every 12 hours; - dated 4/7/23, to administer losartan potassium oral tablet 100 mg by mouth one time a day; - dated 6/27/23, to administer Renvela (use to lower amount of phosphorus in the blood of residents receiving dialysis) oral tablet 800 mg two tablets by mouth three times a day; - dated 8/3/23, to administer Fosrenol (used to lower phosphorus level in the blood) oral packet 1000 mg by mouth with meals; - dated 1/12/24, to administer quetiapine fumarate (antipsychotic) oral tablet 200 mg by mouth two times a day; and - dated 1/28/24, to administer Novolin R (use to lower blood sugar) injection solution per sliding scale subcutaneously before meals and at bedtime. Review of Resident 42's Medication Admin Audit Report dated 2/5/24, showed the following late medication administrations: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 65 of 99 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 02/08/2024 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 - on 2/1/24, the 0700 hours dose for Fosrenol oral packet was administered at 1217 hours. Level of Harm - Minimal harm or potential for actual harm - on 2/1/24, the 0800 hours dose for Renvela oral tablet was administered at 1214 hours. Residents Affected - Few - on 2/1/24, the 0900 hours doses for docusate sodium oral capsule, famotidine oral tablet, dorzolamide HCl-timolol ophthalmic solution, [NAME]-Vite oral tablet, and quetiapine fumarate oral tablet were administered on 1214 hours. - on 2/1/24, the 0900 hours doses for amlodipine besylate oral tablet, and losartan potassium oral tablet were administered at 1218 hours. - on 2/3/24, the 0630 hours dose for Novolin R injection solution was administered at 0823 hours. - on 2/4/24, the 0800 hours dose for Renvela oral tablet was administered at 1146 hours. - on 2/4/24, the 0900 hours doses for losartan potassium oral tablet, docusate sodium oral capsule, dorzolamide HCl- timolol ophthalmic solution, [NAME]-Vite oral tablet, famotidine oral tablet, and quetiapine fumarate oral tablet were administered at 1146 hours. - on 2/4/24, the 0900 hours dose for amlodipine besylate oral tablet was administered at 1147 hours. - on 2/4/24, the 1130 hours dose for Novolin R injection solution was administered at 1250 hours. - on 2/4/24, the 1200 hours dose for Renvela oral tablet was administered at 1147 hours. On 2/7/24 at 0828 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated the licensed nurses had a two-hour window from the scheduled time of the medications, one hour before and one hour after the scheduled time. 3. Review of the facility's P&P titled Medication Orders-Controlled Substance Prescriptions updated 8/19 showed each controlled substance prescription is documented in the resident's medication record with the date, time, and signature of the person receiving the prescription. On 2/5/24 at 1031 hours, an inspection of Medication Cart 1 and storage and concurrent document review was conducted with LVN 4. The reconciliation of the controlled drugs log with LVN 4 was conducted. Review of the blue book log for the controlled drugs for hydrocodone- acetaminophen oral tablet 5-325 mg tablet were signed out for Resident 162 on 2/1/24 at 0824 hours, and 2/4/24 at 2151 hours. Review of Resident 162's medical record was intiated on 2/5/24. Review of the MAR for February 2024 for Resident 162 showed no documented evidence the hydrocodoneacetaminophen oral tablet 5-325 mg was administered to the resident on the above dates and times when the medications were signed out from the narcotic controlled log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 66 of 99 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 02/08/2024 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 On 2/8/24 at 1158 at hours, the DON verified the above findings. Level of Harm - Minimal harm or potential for actual harm 4. Review of the facility's P&P titled Preparation and General Guidelines-Medication Administration-General Guidelines updated 10/19 showed during the medication administration of medications, the medication cart is kept closed and locked when out of sight of medication nurse or aid. No medications are kept on top of the cart. Residents Affected - Few On 2/4/24 at 0934 hours, an observation of medication administration was conducted for Resident 814. During the observation of medication administration, RN 4 was observed leaving a prefilled 10 ml of normal saline syringe on the medication cart while administering the resident's IV medications in Resident 814's room. RN 4 acknowledged the above findings. On 2/8/24 at 1158 at hours, the DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 67 of 99 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 02/08/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for two of 33 final sampled residents (Residents 19 and 107). * The facility failed to follow-up on the Pharmacy Consultant recommendation to place hold parameters for minoxidil (a vasodilator used to treat high blood pressure) medication for Resident 107. * The facility failed to follow-up on the Pharmacy Consultant recommendation to place blood glucose hold parameters for glargine (a synthetic version of human insulin) medication for Resident 19. These failures had the potential to put the residents at risk for adverse consequences related to the medications. Findings: 1. Medical record review for Resident 19 was initiated on 2/4/24. Resident 19 was readmitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed a physician's orders dated 11/25/22, to administer insulin glargine 18 units subcutaneously two times a day for diabetes. Review of the Consultant Pharmacist's Medication Regimen Review for Resident 19 dated 1/14/23, showed to clarify the hold parameters (i.e. hold for blood glucose less than 100 mg/dl). Medications used to treat diabetes can cause hypoglycemia, and should include a blood glucose hold parameter as part of the order. Under the Follow-through section, a handwritten note showed the resident was not on glargine. 2. Medical record review for Resident 107 was initiated on 2/4/24. Resident 107 was readmitted to the facility on [DATE]. Review of Resident 107's Order Summary Report showed a physician's orders dated 9/27/23, to administer minoxidil 2.5 mg two tablets a day for hypertension. Review of the Consultant Pharmacist's Medication Regimen Review for Resident 107 dated 1/14/23, showed to clarify the order to show whether a dose was to be held for a low SBP, DBP, pulse or either/or to avoid medication orders. Under the Follow-through section, a handwritten note showed, done. On 2/8/24 at 1001 hours, an interview and concurrent medical record review for Residents 19 and 107 was conducted with the DON. The DON verified the above findings. When the DON was asked how the facility informed the prescribing physician about the pharmacy consultant's recommendations, the DON stated they called the prescribing physician to inform of the pharmacy consultant's recommendation or give the pharmacy consultant's recommendation form to the physician when they were at the facility. When asked about the pharmacy consultant's recommendation to place blood glucose hold parameters for the glargine medication for Resident 19, the DON could not provide documented evidence to show the nurses clarified the order for blood glucose parameters with the attending physician. When asked about the pharmacy consultant's recommendation to place hold parameters for the minoxidil medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 68 of 99 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 02/08/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm for Resident 107, the DON could not provide documented evidence to show the nurses clarified the order for the hold parameters with the attending physician. When asked how soon the facility should follow-up on the pharmacy consultant's recommendations, the DON stated they tried to follow-up within a week after they received the consultation reports from the pharmacy consultant. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 69 of 99 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 02/08/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 12) was free from the unnecessary drugs. Residents Affected - Few * Resident 12 was administered midodrine (medication to treat low blood pressure) when Resident 12's blood pressure was above the parameter prescribed by the physicians. This failure had the potential for Resident 12 to develop significant side effects such as hypertension (high blood pressure). Findings: Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 1/4/23, to administer midodrine 10 mg one tablet by mouth three times a day for hypertension, and to hold of systolic blood pressure above 130 mmHg. Review of Resident 12's MARs for January and February 2024 showed Resident 12 was administered the midodrine medication when the resident's systolic blood pressure was above 130 mmHg as follows: - On 1/10/24 at 0600 hours, a blood pressure of 134/78 mmHg; - On 1/17/24 at 0600 hours, a blood pressure of 132/70 mmHg; - On 1/20/24 at 1300 hours, a blood pressure of 132/72 mmHg; - On 1/25/24 at 2200 hours, a blood pressure of 135/78 mmHg; - On 1/28/24 at 0600 hours, a blood pressure of 132/74 mmHg; - On 1/31/24 at 0600 hours, a blood pressure of 132/76 mmHg; - On 2/5/24 at 2200 hours, a blood pressure of 132/10 mmHg; - On 2/6/24 at 0600 hours, a blood pressure of 134/66 mmHg; and - On 2/6/24 at 2200 hours, a blood pressure of 131/75 mmHg. On 2/7/24 at 1250 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON verified the midodrine medication was administered to Resident 12 when her blood pressure was above the parameter prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 70 of 99 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 02/08/2024 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** 2. Medical record review for Resident 34 was initiated on 2/4/24. Resident 34 was readmitted to the facility on [DATE]. Review of Resident 34's Order Summary Report showed a physician's orders dated 9/23/23, to administer Lexapro 10 mg by mouth at bedtime for depression. Review of Resident 34's MARs for November, December, January, and February 2024 showed Resident 34 was administered the Lexapro medication from 11/1 to 2/6/24. Further review of Resident 34's medical record failed to show monthly psychotropic summaries were completed for Resident 34 related to the use of the Lexapro medication. On 2/7/24 at 0921 hours, an interview and concurrent medical record review for Resident 34 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings. The MDS Coordinator verified the physician's order for Lexapro medication did not include a specific behavior manifestation for Resident 34. The MDS Coordinator also verified there were no monthly psychotropic summaries completed for Resident 34 related to the use of the Lexapro medication. 3. Medical record review for Resident 49 was initiated on 2/4/24. Resident 49 was readmitted to the facility on [DATE]. Review of Resident 49's Order Summary Report showed a physician's orders dated 10/22/23, to administer sertraline 100 mg one tablet by mouth at bedtime for depression. Review of Resident 49's MARs for January and February 2024 showed Resident 49 was administered the sertraline medication from 1/1 to 2/7/24. Further review of Resident 49's medical record failed to show a monthly psychotropic summary was completed for Resident 49 related to the use of the sertraline medication. On 2/6/24 at 1610 hours, an interview and concurrent medical record review for Resident 49 was conducted with RN 2. RN 2 verified the above findings. RN 2 verified the physician's order for sertraline medication did not include a specific behavior manifestation for Resident 49. RN 2 also verified there was no monthly psychotropic summary completed for Resident 49 related to the use of the sertraline medication. Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of 33 final sampled residents (Residents 21, 34, and 49) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior) as evidenced by: * The facility failed to ensure the PRN orders for lorazepam (antianxiety) and temazepam (hypnotic) medications were limited to 14 days. There was no documented evidence explaining why the PRN orders were extended beyond the 14 days. This failure had the potential for the resident to have adverse complications from the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 71 of 99 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 02/08/2024 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 * The facility failed to ensure the physician's order for Lexapro (antidepressant medication) included a specific behavior manifestation for Resident 34. In addition, the facility failed to complete the psychotropic summary sheets to monitor the number of behavioral episodes related to the use of Lexapro medication for Resident 34. * The facility failed to ensure the physician's order for sertraline (antidepressant medication) included a specific behavior manifestation for Resident 49. In addition, the facility failed to complete a psychotropic summary sheet to monitor the number of behavioral episodes related to the use of sertraline medication for Resident 49. These failures had the potential to negatively affect the residents' well-being. Findings: 1. Review of the facility's P&P titled Psychotropic Medications-Pharmacy Services revised 12/2023 showed PRN orders for psychotropic drugs are limited to 14 days. Except for PRN orders for anti-psychotic medications, if the attending physician or prescribing practitioner believes that is appropriate for the PRN psychotropic medication order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of the facility's P&P titled Consultant Pharmacist Reports-Medication Regimen Review (Monthly Report) updated 8/19 showed the recommendations are acted upon and documented by the facility staff and prescriber. The physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Medical Record review for Resident 21 was initiated on 2/4/24. Resident 21 was initially admitted on [DATE], and readmitted on [DATE]. Review of Resident 21's Physicians Order Summary Report showed the following: - an order dated 1/25/24, to administer lorazepam (antianxiety medication) 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by restlessness for 60 days. - an order dated 11/29/23, to administer temazepam (hypnotic medication) 7.5 mg one tablet by mouth every 22 hours as needed for insomnia. May administer at bedtime one time a day (may be less than 24 hours based on resident sleep cycle). Review of Resident 21's Medication Administration Record for January and February 2024 showed the following: - lorazepam 0.5 mg was administered on 1/26/24 at 1245 and 2050 hours; 1/27/24 at 1640 hours; 1/28/24 at 1614 hours; 1/29/24 at 1622 hours; 1/30/24 at 1622 hours; 1/31/24 at 1553 hours; 2/1/24 at 1522 hours; 2/2/24 at 1607 hours; and 2/3/24 at 1331 and 2135 hours - temazepam 7.5 mg was administered on 1/12/24 at 1931 hours; 1/13/24 at 1951 hours; 1/16/24 at 2100 hours; 1/18/24 at 1830 hours; 1/24/24 at 1954 hours; 1/25/25 at 1907 hours; 1/26/24 at 2050 hours; 1/28/24 at 1951 hours; 1/29/24 at 1914 hours; 1//30/24 at 1914 hours; 1/31/24 at 1921 hours; 2/2/24 at 2057 hours; and 2/3/24 at 2136 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 72 of 99 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 02/08/2024 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 Review of the Medication Regimen Review showed the Consultant Pharmacist recommended for lorazepam 0.5 mg every four hours as needed for anxiety and temazepam 7.5 mg at bedtime as needed to be limited to 14 days. If the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Residents Affected - Few However, further review of the medical record showed no documented evidence the facility had addressed the Consultant Pharmacist's recommendation. There was no documented evidence explaining why the lorazapam and temazepam medications should be administered beyond 14 days. On 2/8/24 at 0938 hours, an attempt to call the Consultant Pharmacist was conducted and a message was left. The Consultant Pharmacist did not call back to discuss the identified concerns. On 2/8/24 1158 hours, the DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 73 of 99 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 02/08/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.82%. Three licensed nurses (LVNs 8, 12, and 17) were found to have made errors during the medication administration for two of 33 final sampled residents (Residents 12 and 61) and one nonsampled resident (Resident 62). Residents Affected - Few * LVN 8 failed to administer the Cholecalciferol Tablet and multivitamin with minerals for Resident 61. * LVN 17 failed to properly administer omeprazole (a medication used to treat gastroesophageal reflux disease (GERD) to suppress stomach acid secretions) for Resident 12. * LVN 12 failed to properly administer the eye drops for Resident 62. These failures had the potential to negatively affect the residents' health conditions. Findings: Review of the facility's P&P titled Preparation and General Guidelines-Medication Administration-General Guidelines dated 10/2019 showed medications are administered in accordance with written orders of the attending physician. 1. Review of Resident 61's Physicians Order Summary Report showed the following orders: - an order dated 6/3/23, for Cholecalciferol Tablet 1000 UNIT one tablet by mouth one time a day for wound healing/supplement. - an order dated 2/4/24, for multivitamin with minerals one tablet via GT one time a day for skin management. On 2/4/24 at 0812 hours, a medication administration observation for Resident 61 was conducted with LVN 8. The following medications were administered to Resident 61. - vitamin C 500 mg 1 tab GT daily - multivitamin one tablet GT daily - metoprolol 25 mg 1/2 tab via GT every 12 hours - nortriptyline 10 mg one tab GT daily - Gemtesa 75 mg via one tab GT daily - Allopurinol 100 mg one tab GT daily - Prostat 30 ml daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 74 of 99 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 02/08/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During the medication administration observation, Resident 61 was not administered a multivitamin with minerals. Review of Resident 61's MAR showed Cholecalciferol Tablet 1000 UNIT (vitamin D) was supposed to be administered at 0900 hours, but was not observed as administered during the above medication administration observation. On 2/4/24 at 1345 hours, an interview was conducted with LVN 8. LVN 8 verified the Cholecalciferon tablet was not given and the incorrect multivitamin was given to Resident 61. 2. According to Lexicomp, omeprazole should be taken 30 to 60 minutes before meal; best taken before breakfast. On 2/4/24 at 0844 hours, a medication administration observation and concurrent interview with Resident 12 was conducted with LVN 17. Resident 12 was observed in bed with a breakfast tray. Resident 12 stated she had eaten her breakfast. During medication administration, omeprazole 40 mg capsule was administered to Resident 12. Review of Resident 12's Physicians Order Summary Report showed an order dated 7/30/21, for omeprazole capsule delayed release 40 mg one capsule by mouth two times a day for GERD. 3. According to Lexicomp, the proper administration to administer eye drops is to instill into conjunctival sac avoiding contact of bottle tip with skin or eye. Apply gentle pressure to lacrimal sac during and immediately following instillation (1 minute) or instruct patient to gently close eyelid after administration, to decrease systemic absorption of ophthalmic drops (Ref). Separate administration of other ophthalmic agents by 5 minutes On 2/4/24 at 1000 hours, a medication administration observation was conducted with LVN 12 for Resident 62. LVN 12 was observed pulling out Resident 62's over the counter medications and stated she wanted to give eye drops first since they had to be administered five minutes apart. The eye drops shown to be administered were: - brimonidine -timolol 0.2-.5 % 1 drop BID both eyes glaucoma - dorzolamide sol 2% 1 drop both eyes TID, to administer 10 minutes LVN 12 was observed to instill the eye drops by lifting upper lid and dropping into the center of each eye Review of Resident 62's Physicians Order Summary Report showed the following orders: - an order dated 1/9/24, for Combigan Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol) one drop to both eyes two times a day for Glaucoma - an order dated 5/26/23, for dorzolamide HCl Solution 2 % one drop in both eyes three times a day for glaucoma, to administer at least 10 minutes apart from brimonidine. On 2/8/24 1158 hours, the DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 75 of 99 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 02/08/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. On [DATE] at 1234 hours, Medication Cart 3 parked in the hallway was observed to be unlocked and unattended. There were several residents noted to be seated in their wheelchairs near the medication cart, a CNA was observed standing across the medication cart, and the visitors were observed passing by. On [DATE] at 1237 hours, the DON was observed in Nursing Station A. When asked who was in charged of Medication Cart 3, the DON answered RN 1 was in charged Medication Cart 3, but she went to give her IV medication at the time. The DON was asked to verify Medication Cart 3 was unlocked and the residents were passing by the medication cart. On [DATE] at 1240 hours, RN 1 verified she left Medication Cart 3 unlocked and unattended. RN 1 stated she forgot to lock Medication Cart 3. When asked what was inside Medication Cart 3, RN 1 opened Medication Cart 3 and several bags of IV antibiotic were observed inside the medication cart. 11. Review of the facility's P&P titled Storage of Medications revised 8/2019 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During the initial tour of the facility on [DATE] at 1145 hours, and [DATE] at 1436 hours, Resident 110 was observed with two chest vapor rub (use to relieve minor throat irritation and cough) ointments at the bedside. On [DATE] at 1335 hours, an observation and concurrent interview was conducted with LVN 16. LVN 16 verified the above finding. LVN 16 stated the chest vapor rub ointments were over the counter and she did not consider them as medications. Medical record review for Resident 110 was initiated on [DATE]. Resident 110 was readmitted to the facility on [DATE]. Further review of Resident 110's medical record did not show a physician's order for the chest vapor rub ointments. On [DATE] at 0836 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above finding. The DON verified Resident 110 did not have a physician's order for the two chest vapor rub ointments. The DON stated over the counter medications brought from home, like the chest vapor rub ointment, needed the physician's orders for use and to keep the medication bedside. The DON stated the licensed nurses were responsible to monitor the residents' room and belongings to ensure there were no medications left at the bedside without a physician's order. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 76 of 99 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 02/08/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure Resident 12's opened stool softener and fish oil were properly labeled and dated in Medication Cart 5. * The facility failed to dispose of the Ozempic pen after 28 days of the open date for Resident 12 in Medication Cart 4. Residents Affected - Some * The facility failed to dispose the single use opened wound care treatments and expired wound care treatments in Medication Cart 4. * The facility failed to ensure a working thermometer was in place inside the refrigerator containing medications for Medication room [ROOM NUMBER]. * The facility failed to dispose expired COVID-19 testing kit in Medication Cart 3. * The facility failed to ensure opened eyedrop medications in Medication Cart 1 were dated. * The facility failed to ensure the refrigerated medications was properly stored. * The facility failed to ensure a pill cutter with residue in Medication Cart 1 was discarded. * The facility failed to dispose of the insulin pens with an opened date beyond 28 days in Medication Cart 3. Additionally, the insulin pens were not labeled with an open date. * The facility failed to ensure Medication Cart 3 was not left unlocked and unattended. * The facility failed to ensure safe storage of two chest vapor rub ointments found at Resident 110's bedside. These failures had potential to result in unsafe medication administration, cross-contamination of the medications, and pose a risk of reduced potency of the medications. Findings: 1. On [DATE] at 0844 hours, a medication administration observation was conducted for Resident 12 with LVN 17. LVN 17 administered stool softner and fish oil to Resident 12. There was no open date on the bottles of stool softener and fish oil. 2. On [DATE] at 0844 hours, a medication administration observation was conducted for Resident 12 with LVN 17. An Ozempic pen showed an open date of [DATE], in Medication Cart 4 for Resident 12. 3. Review of the facility's P&P titled Medication Storage in the Facility-Storage of Medications updated 8/2019 showed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists. On [DATE] at 0810 hours, a concurrent observation, and interview of Medication Cart 4 was conducted with LVN 1. The following was observed and verified by LVN 1: - Equos Wound cleanser 8 fl oz spray bottle with no label of resident name and open date. LVN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 77 of 99 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 02/08/2024 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 0761 verified the cleanser should be discarded. Level of Harm - Minimal harm or potential for actual harm - xeroform packag was observed opened with no label of resident name and open date. LVN 1 verified they should have been discarded. Residents Affected - Some - Calcium Alginate package was observed opened with no label of resident name and open date. LVN 1 verified it should have been discarded. - an opened, half full Sterile 0.9% NS 100 ml bottle was observed opened with no label of resident and open date. LVN 1 verified it should have been discarded. - Xeroform petrolatum had expired on [DATE] - Hydrofera antibacterial foam dressing had expired on [DATE] - a unlabled medication cup with white powder was in drawer. LVN 1 stated the contents was nystatin powder and it should have been discarded. 4. Review of the facility's P&P titled Nursing Clinical-Medication Access and Storage dated [DATE] showed to store all drugs and biologicals in locked compartments under proper temperature controls. Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) , and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. On [DATE] at 0900 hours, a concurrent observation of Medication room [ROOM NUMBER] and interview was conducted with the MDS Coordinator. The thermometer in the Medication room [ROOM NUMBER] refrigerator was not working. The MDS Coordinator stated the thermometer inside the refrigerator was incorrect and stated the wrong thermometer was placed inside the fridge. The freezer was observed to have ice buildup. 5. On [DATE] at 1017 hours, an observation of Medication Cart 3 and concurrent interview was conducted with RN 1. One box of iHealth COVID-19 test kits had expired on [DATE], and an extension was provided with an expiration date of [DATE]. 6. On [DATE] at 1031 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 4. The opened eyedrops and artificial tears bottles did not have open dates. 7. On [DATE] at 1031 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 4. Konvomep 2-84 mg/m was stored in the Medication Cart 1; however, this medication should be refrigerated and discarded after [DATE]. On [DATE] at 1429 hours, an interview was conducted with the DON. When asked, the DON stated the refrigerated medications had to be stored in the refrigerator. 8. On [DATE] at 1031 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 4. A medication pill cutter was observe to have rust and powder residue remaining. LVN 4 stated it should have been discarded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 78 of 99 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 02/08/2024 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 0761 9. On [DATE] at 1116 hours, an observation of Medication Cart 3 and concurrent interview was conducted with LVN 10. The following was observed: Level of Harm - Minimal harm or potential for actual harm - an Insulin pens with dated 12/28, and to be discard after 28 days Residents Affected - Some - an Insulin pen with no open dates - an Insulin pen with an open date of 12/28 - Humalog with an open date of 12/27, and to be discarded after 28 days of the open date - Three Artificial Tears with the open dates of 12/27, [DATE], and [DATE] - Timolol eyedrops with an open date of [DATE]. On [DATE] at 1328 hours, an interview was conducted with LVN 14. LVN 14 was asked about the facility's open date policy for medications and stated he was unsure and would have to check the policy. On [DATE] at 1429 hours, an interview was conducted with the DON. When asked, the DON stated the medication carts were checked daily and as needed. When the DON was asked what the facility policy was for dating the multi dose vials, the DON stated the open date should be written on the medication, and the discard date was usually indicated and written on the medication by the pharmacy. When asked about those medications without dates, the DON stated the medications should be discarded. On [DATE] 1158 hours, the DON acknowledged all the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 79 of 99 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 02/08/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure six of 149 residents who received meals in the facility were provided the correct amount of gravy as directed by the Cook's Spreadsheet. This failure had the potential to provide the residents who received meals in the facility with incorrect nutrients. Findings: Review of the facility's P&P, Menu Planning dated 2023 showed the facility's registered dietitian must sign and date spreadsheets when changes are made. Review of the facility form, Cook's Spreadsheet - Winter Menus dated 2/5/24, showed the lunch meal included one ounce of Cream Gravy to be served over the residents' patty and potatoes. One ounce of Cream Gravy was indicated for regular and therapeutic diets. Review of the facility's Diet Type Report dated 2/6/24, showed 149 residents received meals from the facility. The report showed 36 of 149 residents were on a fortified diet. On 2/5/24 at 1200 hours, an observation of the resident lunch tray line and concurrent interview with the RD was conducted. During the tray line observation, the Assistant Director of Dietary Services/Cook 2 (Assistant DDS/Cook 2) was observed using a two-ounce ladle to fully scoop Cream Gravy onto six residents' lunch trays. When asked, the RD verified the Assistant DDS/Cook 2 used the two-ounce ladle to scoop the gravy. The RD reviewed the Cook's Spreadsheet for 2/5/24, and stated the one-ounce ladle should be used to prepare the Cream Gravy. The RD further stated the fortified diets may have one extra ounce of gravy. When asked about the process for preparing fortified diets, the RD stated they would go by the Cook's Spreadsheet. On 2/8/24 at 1757 hours, the DON and Corporate Clinical Resource were informed and acknowledge the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 80 of 99 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 02/08/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide the food preference for two of 33 final sampled Residents (Residents 3 and 26). This failure had the potential for inadequate nutrition. Findings: Review of the facility's P&P titled Food Preferences dated 2023 showed the resident's food preferences will be adhered to within reason. Substitutes for all food disliked will be given from the appropriated food group. 1. Medical record review for Resident 3 was initiated on 2/4/24. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 3's care plan dated 12/7/23, addressing nutritional problem or potential nutritional problem showed the interventions included to honor the resident rights to make personal dietary choices and provide dietary education as needed. Review of Resident 3's diet orders dated 2/4/24, for breakfast and 2/6/24, for lunch showed Resident 3 disliked eggs and salads. On 2/4/24 at 0800 hours, a concurrent observation and interview was conducted with Resident 3 and CNA 1. Resident 3 was served egg on her breakfast tray. Resident 3 stated they disliked egg and salad, but the facility still served eggs and salad to them. Resident 3's diet card showed the resident disliked eggs. CNA 1 stated he was assigned to Resident 3 but did not serve the breakfast tray. CNA 1 stated CNA 6 helped serve the residents breakfast and did not check the tray because LVNs 1 and 2 had checked the tray already. CNA 1 statated they were just passing the tray. CNA 1 stated the egg should not have been served to Resident 3. CNA 1 verified the findings. On 2/6/24 at 0110 hours, a concurrent observation and interview was conducted with Resident 3 and CNA 2. Resident 3 was served salad on her lunch tray. Resident 3's diet card showed the resident disliked salads. CNA 2 was asked if she was aware Resident 3 disliked salad and the salad was on her tray. CNA 2 stated LVN 1 and the MDS coordinator checked the tray so she did not check and passed the tray. CNA 2 stated the salad should not have been served to Resident 3. CNA 2 verified the finding. 2. Medical record review for Resident 26 was initiated on 2/4/24. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 26's care plan dated 12/28/23, addressing nutritional problem or potential nutritional problem showed the intervention included to honor the resident rights to make personal dietary choices and provide dietary education as needed. On 2/6/24 at 1330 hours, a concurrent observation and interview was conducted with Resident 26. Resident 26 almost finished his lunch. Resident 26's diet card showed he preferred to have ice cream. No ice cream was observed on his lunch tray. Resident 26 was asked if he had received ice cream. Resident 26 stated no, but he would love to have ice cream. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 81 of 99 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 02/08/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/6/24 at 1335 hours, an interview was conducted with CNA 5. CNA 5 was asked if she had served the ice cream for Resident 26's lunch. CNA 5 stated no and Resident 26 should have had ice cream on his tray. CNA 5 verified the finding. On 2/8/24 at 1500 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated everyone should check the diet before serving trays to the residents. Event ID: Facility ID: 555765 If continuation sheet Page 82 of 99 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 02/08/2024 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 0808 Level of Harm - Potential for minimal harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and facility document review, the facility failed to ensure one nonsampled resident (Resident 69 ) was provided with the prescribed therapeutic diet. Residents Affected - Some * Resident 69 was prescribed with a low fat low cholesterol diet food, fat free skim milk. The resident was not provided skim milk or alternative on the lunch tray. This failure had the potential for Resident 69 to not receive adequate nutrition which poses a risk of compromising the resident's nutritional and medical status. Findings: On 2/4/24 at 1224 hours, Resident 69 was observed in the dining room feeding self independently. The resident's dietatry slip (the diet slip is used to identify the resident's ordered diet and food preferences for meal service) on Resident 69's meal tray showed, Regular, low fat, low cholesterol, No Added Salt, Thin liquids with 4 oz skim milk 4 oz prune juice, and dislikes Brussel Sprouts, broccoli, gravy. There was no 4oz of skim milk observed on the resident's tray. On 2/4/24 at 1230 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 was asked to checked the diet slip on Resident 69's tray and if it matched with the items on the tray. LVN 2 stated the resident did not have the the milk. When asked if it did not match what the LVN should do, LVN 2 stated to let the kitchen know what was missing. LVN 2 further stated the kitchen staff was made aware but there was not enough skim milk right now. He stated he did not know what the facility would do if there was no skim milk available. Medical record review was initiated on 2/4/24 for Resident 69. Review of Resident 69's physician's orders showed an order for a low fat low cholesterol diet food, fat free skim milk. On 2/6/24 at 1409 hours an interview was conducted with the RD. The RD was asked how the RD knew about the diet order for the resident. The RD stated upon review and reading the dietary documents for low fat/low cholesterol diet which showed a nutritional breakdown 1800-2000 calories a day, protein 90-100 gm, fat 55-65 gm, carbohydrates 230 -240 gm, cholesterol 300 mg (less than). The RD verified the physician's diet order and she stated the skim milk was placed on the resident's diet slip; however, there was no skim milk yesterday at the time of delivery, and there was no alternative available for the skim milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 83 of 99 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 02/08/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper sanitation was maintained for food prepared by the kitchen when: Residents Affected - Few * The Assistant Director of Dietary Services/Cook 2 (Assistant DDS/Cook 2) failed to perform hand hygiene while preparing pureed food from the kitchen. * The facility failed to ensure Resident 762's dessert was stored and prepared under sanitary conditions when their pumpkin dessert was not covered or wrapped on the resident's meal tray while being transported by the staff to the resident's room. * The facility failed to ensure Resident 1's two bags of chips, five bottles of coke and disposable drinking cups were properly stored. These failures had the potential to cause foodborne illnesses and spread of infection. Findings: Review of the facility's P&P titled Food Preparation dated 2023 showed the facility must not use cleaning products or sanitizer in the food preparation areas, including spraying or pouring products near food items during preparation or cooking. Review of the facility's P&P titled Hand Hygiene revised 10/2022 showed hand hygiene must be performed before or after handling resident food. 1. On 2/5/24 at 1103 hours, an observation was conducted of the kitchen's preparation of pureed food. The Assistant DDS/Cook 2 was observed preparing pureed bread rolls in the X Prep Blender. After transferring the pureed bread from the blender onto the steam tray, the Assistant DDS/Cook 2 retrieved a blue and white wet cloth from under the preparation table and proceeded to wipe the puree preparation table on 2/5/24 at 1120 hours. Immediately after wiping the puree preparation table, the Assistant DDS/Cook 2 was observed scooping meat into the X Prep Blender to puree the meat. The Assistant DDS/Cook 2 did not perform hand hygiene after wiping the puree preparation table. On 2/5/24 at 1132 hours, an interview was conducted with the Assistant DDS/Cook 2. When asked about the wipe used to clean the table during puree preparation, the Assistant DDS/Cook 2 pointed to a red bucket under the table and stated she used a wipe from the sanitation bucket. The Assistant DDS/Cook 2 verified she did not wash her hands after using the sanitizer wipe and before preparing the pureed meat. The Assistant DDS/Cook 2 stated hands should be washed after using sanitizer so sanitizer did not get into the food. On 2/8/24 at 1757 hours, the DON and Corporate Clinical Resource were informed and acknowledge the above findings. 2. On 2/4/24 at 0938 hours, during the initial tour of the facility, Resident 1's night stand was observed with two opened bags of chips on top of the nightstand with no name and open date. Additionally, there were five bottles of coke and disposable drinking cups on the floor beside Resident 1's bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 84 of 99 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 02/08/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm On 2/4/24 at 0940 hours, an interview with CNA 7 was conducted. CNA 7 stated Resident 1 required assistance with eating. CNA 7 verified there were two opened bags of chips on top of the nightstand with no name and open date, and five bottles of coke and disposable drinking cups on the floor beside Resident 1's bed. Residents Affected - Few On 2/4/24 at 1038 hours, an interview was conducted with LVN 9. LVN 9 verified the above findings. On 2/7/24 at 0911 hours, an interview was conducted with the DON. The DON stated the food needed to be in a closed container, labeled, and dated. The food and beverages must not be stored on the floor. The DON was informed and acknowledged the above findings. 3. On 2/4/24 at 1217 hours , an observation and concurrent interview was conducted with the DOR. The DOR was observed walking out of dining room area to Station 1 carrying Resident 762's food tray. Resident 762's pumpkin dessert was uncovered. The DOR confirmed the pumpkin dessert should have been covered and acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 85 of 99 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 02/08/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 94 was initiated on 2/4/24. Resident 94 was admitted to the facility on [DATE], and readmitted on [DATE]. - Review of Resident 94's TAR for January 2024 showed the following enntries were blank: - Monitor indwelling catheter every shift for the day shifts on 1/1, 1/4, 1/6, 1/27/24; night shifts on 1/2, 1/12, 1/14, 1/20, 1/22, 1/25, 1/30, and 1/31/24; and evening shifts on 1/14 and 1/28/24. - Catheter care- cleanse with soap and water and pat dry every shift for the night shifts on 1/25, 1/30, and 1/31/24; day shift on 1/27/24; and evening shift on 1/28/24. Review of Resident 94's TAR for February 2024 showed the following entries were blank: - Monitor indwelling catheter every shift for the evening shifts on 2/2/24; 2/5/24; and night shift on 2/6/24. - Catheter care- cleanse with soap and water and pat dry every shift for the evening shift on 2/2/24; 2/5/24; and night shift on 2/6/24. On 2/7/24 at 1340 hours, a concurrent interview and medical record review was conducted with LVN 7. LVN 7 was asked regarding the above findings and stated the nurse should document if they completed the treatment. LVN 7 verified the above findings. 2. Closed medical record review for Resident 152 was initiated on 2/7/24. Resident 152 was admitted to the facility on [DATE]. Review of Resident 152's H&P Examination dated 12/14/23, showed Resident 152 had the capacity to understand and make decisions. Review of Resident 152's Discharge Summary and Post Discharge Plan of Care dated 1/31/24, showed a planned discharge date for Resident 152 on 1/31/24. The reason for discharge showed Resident 152's health had improved sufficiently, and Resident 152 was no longer needed the services of the facility. The document showed Motel 1 as Resident 152's discharge location and transportation was provided for Resident 152. Additionally, the document showed Resident 152 was to go to Treatment Center 1 on 2/1/24, per request. On 2/8/24 at 1118 hours, a concurrent interview and medical record review was conducted with the SSD. The SSD stated it was determined Resident 152 was ready to discharge back to the community and Resident 152 agreed to discharge to Motel 1. The SSD stated she provided Resident 152 with $150 for the night at Motel 1, and he would be admitted to Treatment Center 1 on 2/1/24. On 2/8/24 at 1238 hours and 1440 hours, a follow-up interview was conducted with the SSD. The SSD stated the DSD called Treatment Center 1 and said they would be accepting Resident 152 on the following day, 2/1/24. When asked where this communication was documented, the SSD verified there was no documented evidence the DSD contacted Treatment Center 1 about Resident 152's discharge. The SSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 86 of 99 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 02/08/2024 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 0842 additionally verified there was no physician's order for Resident 152's discharge. Level of Harm - Minimal harm or potential for actual harm On 2/8/24 at 1546 hours, a concurrent interview and medical record review was conducted with the DSD. The DSD stated she called Treatment Center 1 and the physician regarding the orders for discharge of Resident 152; however, was unable to provide documented evidence of communication. Residents Affected - Few Based on interview and medical record review, the facility failed to ensure accurate and complete medical records for two sampled residents (Residents 61 and 94) and one closed record sample resident (Resident 152). * Resident 61's physician's order was not consistent with the resident's condition. * The facility failed to ensure the discharge documentation was completed for Resident 152. * The facility failed to ensure the TAR was completed to show the treatment was administered for Resident 94. These failures had the potential to result in medication error and delay of care administration; and potential for lack of follow up. Findings: 1. On /7/24 at 1300 hours, medical record review was intiated for Resident 61. Resident 61 was admitted to the facility on [DATE]. Review of the physician's order dated 1/12/24, and MAR for January and February 2024 showed an order for Nortryptiline HCL oral capsule 10 mg one capsule by mouth one time a day for depression manifested by sad facial expression. However, further review of Resident 69's medical record showed the resident had a GT with orders for nothing by mouth or NPO. On 2/8/24 at 2000 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 87 of 99 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 02/08/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of hospice services for one of 33 final sampled residents (Resident 32). * The facility failed to ensure Resident 32 had hospice visitation calendar projection for each month showing the scheduled visits of the hospice's staff. There was no coordination regarding the care plan. This failure had the potential for not providing the timely, appropriate, and consistent care to Resident 32. Findings: Review of the facility's P&P titled End of Life Care: Hospice and/or Palliative Care dated 1/2022 showed a care plan will be developed based on the individualized assessments, the desire of the resident/surrogate decision maker, and the physician's orders. Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with the Hospice will include processes for orienting staff to facility policies and procedures which include resident's rights, documentation and record keeping requirements. Review of the facility's admission Agreement with Hospice A effective date 1/9/23, showed the hospice and facility shall develop a process to exchange information between the Interdisciplinary Group and facility staff regarding development and updating the POC (Plan of Care) and evaluation of the care outcomes to ensure that each Hospice resident receives necessary and appropriate care services. Medical record review for Resident 32 was initiated on 2/6/24. Resident 32 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 32's physician's order dated 4/15/23, showed an order to admit to Hospice A with diagnosis of Coronary Artery Disease (damage or disease in the heart's major blood vessels due to build up of plaque causing narrowing and limiting blood flow to the heart) , nursing visit 1x a week (one visit a week). Review of Resident 32's Hospice A Monthly Visit Calendar for January 2024 showed Hospice A's nurse had visited Resident 32 on 1/1 and 1/6/24. There was no documented visit for the rest of the month of January 2024 and from 2/1 to 2/6/24. Review of Resident 32's care plan showed a care plan problem dated 3/27/23, addressing Resident 32's terminal prognosis related to coronary artery disease. Resident 32's plan of care failed to show Hospice A's nurse documented to acknowledge the facility's plan of care, nor Hospice A nurse had co-signed indicating the care plan was reviewed. On 2/6/24 at 1239 hours, an interview and concurrent medical record and facility document review was conducted with the SSD who was also the facility's Hospice Coordinator. The SSD was asked if Resident 32 had monthly hospice nurse visitation calendar projections. The SSD was not able to present the planned visit schedule, and verified there was no monthly calendar projection. The SSD stated she would ask Hospice A for the monthly visitation calendar projections. The SSD was asked regarding the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 88 of 99 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 02/08/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few coordination between the facility and Hospice A on Resident 32's plan of care. The SSD verified there was no care plan coordination between the facility and Hospice A. Hospice A had their own plan of care in their binder but was not coordinated with the facility and it was kept sometimes in the social services office or nurses station. On 2/6/24 at 1445 hours, an interview was conducted with LVN 10. When asked, LVN 10 stated Hospice A's binder with the resident's care plan was kept by the social services in her office. On 2/7/24 at 0948 hours, an interview was conducted with LVN 11. When asked about the hospice's binder with care plan, LVN 11 stated it was with the SSD and was not all the time in the nurse station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 89 of 99 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 02/08/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8.a. On 2/4/24 at 1030, 1035, and 1057 hours, an Enhanced Barrier Precaution sign was observed posted outside Resident 105's room alerting anyone to perform hand hygiene before entering and when leaving the room. The sign also alerted the providers and staff to wear gloves and a gown for high-contact resident care activities. A cart containing gowns was observed under the posted enhanced standard precautions sign. Residents Affected - Some Medical record review for Resident 105 was initiated on 2/4/24. Resident 105 was readmitted to the facility on [DATE]. Review of Resident 105's Order Summary Report showed a physician's order dated 12/17/23, for contact isolation for MRSA (Methicillin-resistant Staphylococcus aureus infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used) on the left foot diabetic ulcer (an open sore or wound that occurs in people with diabetes, and is commonly located on the bottom of the foot), and candida infection (a fungal infection caused by a yeast or fungus called Candida) every shift. On 2/5/24 at 0850 hours, a Contact Precaution sign was observed posted outside Resident 105's room alerting anyone to perform hand hygiene before entering and when leaving the room. The sign also alerted the providers and staff to wear gloves and a gown before room entry, discard gloves and the gown before room exit, and to use dedicated or disposable equipment. A cart containing gowns was observed under the posted enhanced standard precautions sign. b. On 2/4/24 at 1030 and 1035 hours, a cart containing gowns was observed under the posted enhanced standard precautions sign, but there was no isolation sign observed by the resident's door. Medical record review for Resident 512 was initiated on 2/4/24. Resident 512 was readmitted to the facility on [DATE]. Review of Resident 512's Order Summary Report showed a physician's order dated 2/5/24, for contact isolation for MRSA to the left stump. On 2/4/24 at 1035 hours, an observation and concurrent interview Residents 105 and 512 was conducted with LVN 17. LVN 17 verified the above findings. LVN 17 verified there was no isolation sign observed by Resident 512's door. When asked about Resident 512's isolation, LVN 17 stated Resident 512 was on enhanced precaution which was the same as Resident 105's isolation. On 2/4/24 at 1048 hours, Resident 512 was observed sitting in a wheelchair in the room. An Enhanced Barrier Precaution sign was observed posted outside Resident 512's room. On 2/5/24 at 0850 hours, a Contact Precaution sign was observed posted outside Resident 512's room. A cart containing gowns was observed under the posted enhanced standard precautions sign. On 2/8/24 at 1434 hours, an interview and concurrent medical record review for Residents 105 and 512 was conducted with LVN 17. LVN 17 verified the above findings. LVN 17 verified the Enhanced Barrier Precaution signs were posted outside Residents 105 and 512's door. LVN 17 stated the Contact Isolations signs should have been posted outside Residents 105 and 512's door, to match the physician's order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 90 of 99 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 02/08/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of the facility P&P titled Infection Prevention- Linen Management, undated, showed soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and personal handling of the linen. Under the procedure section showed clean linen are to be kept covered and protected from dust and other contamination prior to use, clean linen should not touch the floor when folded, clean and dirty linen areas should be separate and clearly designated. Only clean linens are transported on clean carts and only dirty linens are transported in container designated for dirty linens. a. On 2/6/24 at 1601 hours, a laundry area observation and concurrent interview was conducted with the IP. Laundry Aide 1 was observed taking clean linen out of the dryer. Laundry Aide 1 dropped a clean linen on the floor. Laundry Aide 1 picked up the linen from the floor and put it in the bin with other clean linen. The IP verified the finding and stated Laundry Aide 1 should not have picked up the linen from the floor and put it in the bin with other clean linens. b. On 2/6/24 at 1608 hours, a concurrent laundry observation and interview was conducted with the Housekeeping Supervisor. There were four carts with soiled linen in the clean laundry area touching the cover of the clean linen cart. The Housekeeping Supervisor verified the observation and stated the carts with soiled linen should not have been in the clean laundry area. Additionally in the laundry room, a clean linen bin containing clean socks and gowns was observed with no cover. The Housekeeping Supervisor verified the observation and stated the bin containing clean socks and gowns should have been covered to prevent the environmental contamination. On 2/7/24 at 1617 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper infection control as evidenced by: * The facility failed to perform infection surveillance for 23 of 23 residents (Resident 7, 13, 14, 20, 21, 24, 31, 42, 46, 59, 78, 90, 92, 97, 110, 132, 134, 135, 136, 762, 763, 1012, and 1013) during their COVID-19 outbreak. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when Laundry Aide 1 was observed picking linen from the floor and then putting it in a clean laundry bin with other clean laundry. Additionally, the soiled linen carts were kept in the clean linen area touching the cover of a clean linen cart and the clean laundry bin was not covered. * Rooms A, B, and C had posted signage outside of the rooms for contact/droplet/respiratory precaution. The facility failed to ensure the doors for Rooms A, B, and C were closed. * The facility failed to ensure the staff practiced the contact/droplet/respiratory precaution when entering Room B that had posted signage outside of the room for contact/droplet/respiratory precaution and required personal protective equipment (PPE). * LVN 13 failed to change gloves and perform handwashing after administering medications to Resident 42 and before repositioning Resident 136. * The facility failed to ensure Resident 36's Pleur-evac (collects drainage from a chest tube) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 91 of 99 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 02/08/2024 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 0880 chest drainage system was discarded properly and timely. Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure LVN 9 performed hand hygiene after removing PPE from a contact isolation room. Residents Affected - Some * The facility failed to ensure the correct isolation signages were posted by the residents' doors for Residents 105 and 512. These failures had the potential to transmit communicable diseases and infections to the residents living in the facility. Findings: 1. Review of the facility's P&P, Infection Prevention and Control Program, revised 10/2023, showed that the facility should provide surveillance of infections among residents by maintaining a record of infection incidences and corrective action taken. On 2/7/24 at 1309 hours, an interview was conducted with the DSD/IP. When asked how the facility provided infection surveillance, the DSD/IP stated they used an Infection Prevention and Control Surveillance Log and a facility map to monitor infections that occurred in the facility. When a resident has an infection, the team will discuss the resident's infection and symptoms during their clinical meeting. At that time, the IP should complete the Infection Prevention and Control Surveillance Log. The facility map of infections should also be completed to distinguish where the different infections are located in the facility. When asked about COVID-19, the DSD/IP stated one positive case of COVID-19 was considered as an outbreak. The DSD/IP further stated the facility had a current COVID-19 outbreak which started on 1/16/24. When asked if they had their Infection Prevention and Control Surveillance Log or facility map of infections for the COVID-19 outbreak, the DSD/IP stated it was not started and it should have been done. On 2/7/24 at 1526 hours, a follow-up interview and concurrent record review was conducted with the DSD/IP. When asked for the list of residents who tested positive for COVID-19 since the start of their outbreak, the DSD/IP reviewed the medical records and stated the following: a. Resident 59 was tested positive for COVID-19 on 1/16/24. b. Resident 90 was tested positive for COVID-19 on 1/17/24. c. Resident 13 was tested positive for COVID-19 on 1/21/24. d. Resident 42 was tested positive for COVID-19 on 1/25/24. e. Resident 134 was tested positive for COVID-19 on 1/25/24. f. Resident 24 was tested positive for COVID-19 on 1/29/24. g. Resident 7 was tested positive for COVID-19 on 1/25/24. h. Resident 762 was tested positive for COVID-19 on 1/25/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 92 of 99 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 02/08/2024 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 0880 i. Resident 1013 was tested positive for COVID-19 on 1/25/24. Level of Harm - Minimal harm or potential for actual harm j. Resident 110 was tested positive for COVID-19 on 1/25/24. k. Resident 763 was admitted to the facility on [DATE], with a positive COVID-19 test. Residents Affected - Some l. Resident 136 was tested positive for COVID-19 on 1/29/24. m. Resident 135 was tested positive for COVID-19 on 1/29/24. n. Resident 1012 was tested positive for COVID-19 on 1/31/24. o. Resident 21 was tested positive for COVID-19 on 1/31/24. p. Resident 78 was tested positive for COVID-19 on 1/31/24. q. Resident 31 was tested positive for COVID-19 on 1/31/24. r. Resident 132 was tested positive for COVID-19 on 1/31/24. s. Resident 20 was tested positive for COVID-19 on 1/31/24. t. Resident 14 was tested positive for COVID-19 on 1/31/24. u. Resident 92 was tested positive for COVID-19 on 2/3/24. v. Resident 46 was tested positive for COVID-19 on 2/3/24. w. Resident 97 was tested positive for COVID-19 on 2/3/24. The DSD/IP verified the facility had a total of 23 positive COVID-19 cases since the start of their outbreak on 1/16/24, and stated they did not have the COVID-19 Surveillance Log. On 2/8/24 at 1757 hours, the DON and Corporate Clinical Resource were informed and acknowledge the above findings. 3.a. Review of the facility's P&P titled Emerging Infectious Disease (EID): Coronavirus Disease 2019 (COVID-19) revised 11/8/22 showed it is the facility's policy to implement recommended appropriate infection control strategies, guidance, and standards from the local, State, and Federal agencies for an EID event. The policy showed to include preparatory plans and actions to respond to the threat of the COVID-19 (an infectious disease caused by a virus), including but not limited to infection prevention and control practices in order to prevent transmission. In addition, the policy showed to place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). On 2/4/24 at 0959 hours, the door for Room A was observed halfway open. A posted signage outside of the room was observed and showed the following: (a) Entering RED room, (b) You need the following PPE: N95 (use to protect the wearer from breathing in small particles in the air such as dust and mold) mask, face shield or goggle, gown, gloves, (c) contact/droplet/respiratory isolation. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 93 of 99 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 02/08/2024 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 0880 140 was observed directly across Room A's door, sitting in his wheelchair. Level of Harm - Minimal harm or potential for actual harm On 2/4/24 at 1002 hours, the door for Room A was observed halfway open. Resident 140 was observed directly across Room A's door, sitting in his wheelchair. LVN 16 was observed parking her medication cart by Room A. Residents Affected - Some On 2/4/24 at 1012 hours, an obsevation and concurrent interview was conducted with LVN 16. The door for Room A was observed halfway open. LVN 16 was observed telling a visitor that for Room A, they needed to don PPE prior to entering the room. LVN stated Room A was on COVID-19 isolation precaution. LVN 16 verified the door for Room A was opened when she parked the medication cart by Room A. b. On 2/4/24 at 1040 hours, the door for Room B was observed open. A posted signage outside of the room was observed and showed the following: (a) Entering RED room, (b) You need the following PPE: N95 mask, face shield or goggle, gown, gloves, (c) contact/droplet/respiratory isolation. c. On 2/4/24 at 1045 hours, the door for Room C was observed open. A posted signage outside of the room was observed and showed the following: (a) Entering RED room, (b) You need the following PPE: N95 mask, face shield or goggle, gown, gloves, (c) contact/ droplet/ respiratory isolation. On 2/4/24 at 1048 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated the door for the rooms with contact/droplet/ respiratory precaution were preferred to be closed. However, LVN 1 stated if the residents preferred to keep the door open, then the doors would have to kept open. LVN 1 was observed asking the residents in Rooms B and C if the door could be closed. LVN 1 was observed closing the doors for Rooms B and C. 4. Review of Room B's posted signage outside of the room showed the following: (a) Entering RED room, (b) You need the following PPE: N95 mask, face shield or goggle, gown, gloves, (c) contact/droplet/respiratory isolation. On 2/6/24 at 1024 hours, an observation and concurrent interview was conducted with CNA 14. CNA 14 was observed inside Room B providing care for Resident 24. CNA 14 was observed wearing a yellow gown, gloves, and surgical mask. CNA 14 stated she was aware Resident 24 was on contact/droplet/respiratory precaution and to also don the N95 mask and googles. However, CNA 14 stated she did not don the N95 mask because it was hard for her to breathe with the N95 mask on. CNA stated she forgot to don the goggles and left it outside the room. On 2/6/24 at 1030 hours, an observation and concurrent interview was conducted with LVN 10. LVN 10 was observed entering Room B wearing two surgical masks, goggles, yellow gown, and gloves. LVN 10 was observed speaking with Resident 42. LVN 10 stated she was also supposed to don the N95 mask prior to entering Room B. LVN 10 stated she was aware of the PPE needed and the type of isolation precaution that Resident 42 had because she saw the posted signage outside of the room. 5. Review of the facility's P&P titled Universal Precautions (undated) showed using good technique hands shall be washed: (a) before and after resident contact, (b) after contact with blood or body fluids, and (c) after removing gloves. Review of the facility's P&P titled Medication Administration- General Guidelines revised 10/2019 showed the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling medications, after coming in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 94 of 99 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 02/08/2024 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 0880 direct contact with a resident. Level of Harm - Minimal harm or potential for actual harm On 2/4/24 at 1214 hours, LVN 13 was observed administering medications to Resident 42 while wearing a yellow gown, gloves, N95 mask and face shield. Residents Affected - Some On 2/4/24 at 1215 hours, LVN 13 was observed turning off the enteral feeding machine and repositioning Resident 134, wearing the same PPE and gloves that she used during the medication administration for Resident 42. On 2/4/24 at 1218 hours, an interview was conducted with LVN 13. LVN 13 verified she wore the same gloves when she administered medications to Resident 42 and turned off the enteral feeding machine and repositioned Resident 134. 6. During the initial tour of the facility on 2/4/24 at 0811 hours, Resident 36 was observed in bed. The Pleur-evac chest drainage canister was observed on the floor and the open end of the Pleur-evac tubing (where it connects to the resident) was placed on top of the dresser. The Pleur-evac tubing was not connected to Resident 36. The Pleur-evac chest drainage canister and tubing were observed and filled with yellow tinged fluid. On 2/4/24 at 0832 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above finding. LVN 1 stated the tubing should be kept clamped because the fluid contents could leak out. LVN 1 stated the Pleur-evac chest drainage system should be discarded in the biohazard. On 2/6/24 at 1321 hours, an interview and concurrent medical record review was conducted with the IP. The IP was informed and acknowledged the above findings. The IP stated the door for the rooms with contact/droplet/respiratory precaution should be closed at all times. However, the IP stated if the resident was high risk for fall, then the door could be kept slightly open to monitor the resident. The IP stated the facility staff were expected to follow the PPE requirements posted outside of the room. The IP stated the facility staff were expected to change their gloves and perform hand hygiene between each resident care. On 2/7/24 at 0941 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON verified the Pleur-evac chest drainage system was not being used by Resident 36. The DON stated the facility did not manage the chest tubes and she was unaware Resident 36 had the drainage system at the bedside. The DON stated the department managers made rounds to all the residents' rooms at least two times a day, from Monday through Friday; and the manager on duty was responsible to make rounds and check the residents' rooms for infection control concerns. 7. During the initial facility tour on 2/4/24 at 1038 hours, LVN 9 removed their PPE when leaving Resident 162's room which was a contact isolation room and did not perform hand hygiene. On 2/4/24 at 1040 hours, an interview was conducted with LVN 9. LVN 9 confirmed she should perform hand hygiene after coming out of a contact isolation room and removing the PPE. On 2/7/24 at 0911 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 95 of 99 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 02/08/2024 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 0881 Implement a program that monitors antibiotic use. 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 provide the antibiotic stewardship for the residents as evidenced by: Residents Affected - Some * The facility failed to monitor antibiotic use for 33 of 33 residents who were ordered antibiotics in January 2024. * The facility failed to identify Residents 20 and 100's antibiotic use did not meet McGeer's criteria to notify the physician to evaluation of the prescribed antibiotics. These failures had the potential to expose the residents to the adverse effects of unnecessary antibiotic use. Findings: Review of the facility's P&P titled Antibiotic Stewardship revised 1/2022 showed the facility must assess residents for any infection using McGeer's criteria. 1. Review of the facility's Order Listing Report for January 2024 showed 33 residents were prescribed with antibiotics and anti-infective agents. On 2/7/24 at 1309 hours, an interview was conducted with the DSD/IP. When asked how the facility provided antibiotic stewardship, the DSD/IP stated the facility used McGeer's criteria to monitor their antibiotic use. When antibiotics or antivirals were ordered for the residents, the IP would complete the Infection Surveillance Log and a Surveillance Data Collection Form, which helped the facility reviewed the ordered antibiotics using McGeer's criteria. The forms should be completed it right away during their team clinical meeting. On 2/8/24 at 0822 hours, a follow-up interview and concurrent record review was conducted with the DSD/IP. When asked about McGeer's criteria, the DSD/IP stated the facility used the Surveillance Data Collection Form to determine if a resident's infection symptoms met McGeer's criteria. If a resident is ordered an antibiotic and did not meet McGeer's criteria, the IP or nurse should notify the physician to reevaluate the antibiotic treatment. When asked how they provided antibiotic stewardship for the 33 residents ordered antibiotics in January 2024, the DSD/IP stated they did not complete Surveillance Data Collection Forms for January 2024. The DSD/IP stated it should have been done. 2. Medical record review for Resident 100 was conducted on 2/8/24. Resident 100 was admitted to the facility on [DATE], with diagnoses including COPD. Review of the Order Listing Report for January 2024 showed Resident 100 had an order dated 1/22/24, for Levaquin oral tablet 750 mg one tablet by mouth in the evening for pneumonia for seven days. Review of Resident 100's MAR for January 2024 showed the resident received the Levaquin from 1/22/24 to 1/28/24. Review of Resident 100's Change in Condition Form dated 1/22/24, showed Resident 100 had symptoms of a productive cough, shortness of breath, and anxiousness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 96 of 99 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 02/08/2024 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 0881 Review of Resident 100's Radiology Results Report dated 1/22/24, showed x-ray results of clear lungs. Level of Harm - Minimal harm or potential for actual harm On 2/8/24 at 0822 hours, a concurrent interview and record review was conducted with the DSD/IP. When asked if a Surveillance Data Collection Form was completed for Resident 100, the DSD/IP stated no. When asked if Resident 100 met McGeer's criteria, the DSD/IP reviewed a blank Surveillance Data Collection Form for respiratory tract infections and stated Resident 100 did not meet McGeer's criteria. When asked if the physician was informed that Resident 100 did not meet McGeer's criteria for antibiotic use, the DSD/IP stated no. Residents Affected - Some 3. Medical record review for Resident 20 was conducted on 2/8/24. Resident 20 was admitted to the facility on [DATE], with diagnoses including dementia. Review of the Order Listing Report for January 2024 showed Resident 20 had an order dated 1/5/24, for Keflex oral capsule 500 mg one capsule by mouth every eight hours for UTI for seven days. Review of Resident 20's MAR for January 2024 showed the resident received Keflex from 1/6/24 to 1/12/24. Review of Resident 20's Change in Condition Form dated 1/4/24, showed Resident 20 had symptoms of increased confusion. On 2/8/24 at 1623 hours, a concurrent interview and record review was conducted with the DSD/IP. When asked if a Surveillance Data Collection Form was completed for Resident 20, the DSD/IP stated no. When asked if Resident 20 met McGeer's criteria, the DSD/IP reviewed a blank Surveillance Data Collection Form for urinary tract infections and stated Resident 20 did not meet McGeer's criteria. When asked if the physician was informed that Resident 20 did not meet McGeer's criteria for antibiotic use, the DSD/IP stated no. On 2/8/24 at 1757 hours, the DON and Corporate Clinical Resource were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 97 of 99 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 02/08/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **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 ensure the residents' entrapment assessments were completed for two of 33 final sampled residents (Resident 12 and 34). This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Rails revised 12/2023 showed if a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. After the facility has attempted alternatives to bedrails and determined that these alternatives failed to meet the resident's assessed needs, the facility IDT will assess the resident for risks of entrapment. The risks and benefits regarding the use of bed rails will be considered for each resident. 1. On 2/4/24 at 1017 hours, 2/5/24 at 1215 hours, and 2/6/24 at 0918 hours, Resident 12 was observed in a bariatric bed with bilateral ½ side rails elevated. Medical record review for Resident 12 was initiated on 2/4/24. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 was cognitively intact and required partial/moderate assistance of one staff for bed mobility and transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 98 of 99 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 02/08/2024 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 12's Order Summary Report showed a physician's order dated 9/15/21, for bariatric bed with bilateral ½ side rails as enabler for turning and repositioning. Review of Resident 12's Bed Rail Safety Evaluation dated 2/1/24, under the Bed Rail Equipment Fitting section, showed the equipment safety check by maintenance was completed on 11/13/23, using a manual review system. The evaluation form did not show an entrapment assessment was completed. Further review of Resident 12's medical records failed to show documented evidence a side rail entrapment assessment was completed and documented. 2. On 2/4/24 at 1343 hours, 2/5/24 at 0847 hours, 2/6/24 at 0844 hours, and 2/7/24 at 0858 hours, Resident 34 was observed in bed with bilateral grab rails elevated. Medical record review for Resident 34 was initiated on 2/4/24. Resident 34 was readmitted to the facility on [DATE]. Review of Resident 34's MDS dated [DATE], showed Resident 34 was cognitively intact and required partial/moderate assistance of one staff for bed mobility and transfer. Review of Resident 34's Order Summary Report showed the following physician's orders dated: - 9/10/21, for bilateral grab bars to aid in turning and repositioning; - 4/5/22, for perimeter bed or large bed for safe bed mobility and fall prevention; and - 4/1/22, for perimeter bed for spatial orientation. Review of Resident 34's Bed Rail Safety Evaluation dated 10/10/23, showed the Bed Rail Equipment Fitting section was blank. The document did not when the equipment safety check was completed by the maintenance staff. In addition, the evaluation form did not show an entrapment assessment was completed. On 2/8/24 at 1018 hours, an interview and concurrent document review for Residents 12 and 34 was conducted with the Maintenance Director. The Maintenance Director stated he installed the side rails as soon as he received the resident's consent form. The Maintenance Director also stated the maintenance department was responsible for bed inspection and entrapment assessment. The Maintenance Director stated he documented his bed inspection to which he showed the Bed Rail 7 Zones Entrapment Assessment forms. - Review of the Bed Rail 7 Zones Entrapment Assessment for Resident 12 dated 11/13/23, under the Bed Safety Audit section, showed Zones 1 to Zones 7 were left blank. The document did not show whether the bed inspection was passed or failed. The Mattress Safety Audit section also showed Resident 12 had Level 1 type of mattress for regular foam mattress, and not Level 2 for perimeter mattress. Review of the Bed Rail 7 Zones Entrapment Assessment for Resident 34 dated 11/13/23, , under the Bed Safety Audit section, showed Zones 1 to Zones 7 were left blank. The document did not show whether the bed inspection was passed or failed. The Maintenance Director verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555765 If continuation sheet Page 99 of 99

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Citations

37 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0552GeneralS&S Dpotential for harm
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
0553GeneralS&S Bno actual harm
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0583GeneralS&S Dpotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
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.
0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Bno actual harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Bno actual harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0808GeneralS&S Bno actual harm
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Epotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0909GeneralS&S Dpotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

FAQ · About this visit

Common questions about this visit

What happened during the February 8, 2024 survey of THE HILLS POST ACUTE?

This was a inspection survey of THE HILLS POST ACUTE on February 8, 2024. The surveyor cited 37 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE HILLS POST ACUTE on February 8, 2024?

Yes, 37 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·February 8, 2024