Inspection·June 25, 2024

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** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 2, 3, and 8) were complete and accurate. * The facility failed to ensure the licensed nurse documented the blood sugar levels and medications administered to Resident 2 in the MAR. * The facility failed to ensure the licensed nurse documented the blood sugar levelsand insulin medication administered to Resident 3 in the MAR. * The facility failed to ensure the licensed nurse documented the initials in the MAR when Resident 8's medications were administered. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and incomplete. Findings: Review of the facility's P&P titled Specific Medication Administration Procedures dated 10/2019, showed to obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration; and after the administration of medication, return to the cart, replace medication container, and document the administration in the MAR or TAR. Review of the facility's P&P titled Obtaining a Fingerstick Glucose Level (undated) under the section for Documentation showed the person performing this procedure should record the following information in the resident's medical record: - the date and time the procedure was performed, - the name and title of the individual who performed the procedure, - all assessment data obtained during the procedure, - how the resident tolerated the procedure, - if the resident refused the procedure, the reason(s) why and the intervention taken, (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 4 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 06/25/2024 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)