Health inspection·February 14, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **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 appropriate dietary texture was provided for one of four sampled residents (Resident 1) as ordered by the physician. * The facility failed to ensure Resident 1 was provided with the appropriate food texture as per the physician's diet orders. This failure had put Resident 1 at risk for choking. Findings: Review of the facility's document titled Regular Pureed Diet dated 2020 showed the pureed diet is a regular diet that has been designed for the residents who have difficulty chewing and/or swallowing. The texture should be of a smooth and moist consistency and able to hold its shape. Foods such as cakes, cookies, pancakes, and breads may be soaked in milk syrup or slurries until the proper consistency is achieved. Additionally, the document showed the breads may be soaked in liquids such as milk, soup, broth or gelatin water or pureed; and under the miscellaneous section to avoid showed no peanut butter. Review of the facility's document titled Snack Spreadsheet (undated) showed if there is an x in the box, this item is not allowed. Further review of the Snack Spreadsheet showed the peanut butter sandwich and PB (peanut butter) and jelly sandwiches were marked with an x for the residents on pureed diet. Closed medical record review for Resident 1 was initiated on 2/11/25. Resident 1 was admitted to the facility on [DATE], and had expired in the facility on 2/5/25. Resident 1's diagnoses included dysphagia, acute respiratory failure, epilepsy, and autism. Review of Resident 1's H&P examination dated 12/8/24, showed Resident 1 had a fluctuating capacity to understand and make medical decisions. Review of Resident 1's BIMS dated 12/7/24, showed a score of 01 indicating severe cognitive impairment. Review of Resident 1's Progress Note and Change in Condition Evaluation dated 1/8/25, showed the resident had a choking episode with subsequent seizure like activity. Review of Resident 1's ST Progress Notes dated 1/8/25, showed Resident 1's diet was downgraded to (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 2 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 02/14/2025 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)