Other·April 12, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification visit. Representing the Department of Public Health: Health: Health Facilities Evaluator Nurse ID: 36627 Health: Health Facilities Evaluator Nurse ID: 34659 Facility Census: 66 Sample Size: 17 Randomly Selected Residents: 2 Highest Severity and Scope: G

F577 SS=B Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 03/21/2018 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 1 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to observe the residents' rights for six out of seven residents who attended the Group Interview, to examine the most recent survey results and the plan of correction in effect, by failing to: 1. Post a notice of the most recent survey result availability for Station 1 and Station 2. 2. Label the survey result binder in Station 1 and Station 2. 3. Post the most recent survey result in Station 2. As a result, the residents' were not aware the most recent survey results were available for review. Findings: On February 21, 2018 at approximately 11:15 a.m., during a group meeting, six out of seven residents stated they were not aware of the survey results that were available for review. On February 23, 2018 at 7:45 a.m., there was a black binder on the wall, but the binder was not labeled to indicate that it was a survey result binder for Station 1 and Station 2. Station 2's binder did not have the latest survey result posted in the binder (2015 result). Since the binder was not labeled, residents and visitors would not know to access and to examine the most recent survey of the facility conducted by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 2 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Federal or State surveyors and the facility's plan of correction in effect. On February 23, 2018 at 8:00 a.m., during an interview, the Director of Nursing (DON) stated there are no signs posted for the availability of the survey result binders. The DON stated the facility will make a sign indicating the survey results and will post the sign so that the public and residents can access the survey results. A review of the facility's revised policy and procedure dated August 2009, titled "Resident Rights," indicated Federal and State laws guarantee certain basic rights to all residents of this facility to include to examine survey results.

F623 SS=B Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 03/21/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 3 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 4 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a resident's (Resident 67) notice of discharge or transfer was provided to the resident and/or resident's representative that included a right to appeal and the Office of the State Long-Term Care Ombudsman contact information was correct, and a notice of discharge or transfer was sent to the Office of the State Long-Term Care Ombudsman for one of 17 sample residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 5 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Resident 67). This had the potential to result in an unsafe discharge. Findings: A review of the admission record indicated Resident 67 was admitted to the facility on October 25, 2017. A review of the Physician's Order dated December 1, 2017, indicated to discharge Resident 67 to home with medications. A review of the Notice of Discharge/Transfer form with the Director of Nurses (DON), indicated the telephone number on the form for the State Agency and the Office of the State Long-Term Care Ombudsman were incorrect. The form also included the resident's right to appeal and its contact information. On February 23, 2018 at 9:07 a.m., during an interview, the DON stated the facility had a notice of discharge/transfer form but are not providing the form for resident upon discharge to home and was not aware that the Office of the State Long-Term Care Ombudsman needed to be notified prior to discharging the resident.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/21/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 6 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement the comprehensive person-centered plan of care for four of 17 sample residents (Residents 10, 24, 21 and 42) by failing to: 1. Implement the interventions for dental care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 7 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when resident reported loose fitted denture (Resident 10) . 2. Implement the interventions for hospice (providing care for the sick, especially the terminally ill) care plan for Registered Nurse (RN) visits (Resident 42) and RN and volunteer visits (Resident 24). 3. Develop and implement a care plan to prevent a urinary tract infection (UTI-an infection of the kidney, ureter, bladder, or urethra) for a resident (Resident 21) who had a history of UTI and was prone for reoccurence of UTI. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: a. A review of the admission record indicated Resident 10 was admitted to the facility on November 24, 2016, with diagnoses that included muscle weakness. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated February 21, 2017, indicated Resident 10 had intact cognitive skills for daily decision making. The MDS indicated Resident 10's dental status was not checked for broken or loosely fitting full or partial denture. On February 20, 2018 at 8:40 a.m., Resident 10 was observed to be awake, alert, and calm. In a concurrent interview during the observation, Resident 10 stated her lower denture was not fitting well and she had reported the denture problem to the staff, but FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 8 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE did not remember who she reported it to. A review of the care plan for Dental Care initiated on November 24, 2016 and last revised on February 2018, indicated Resident 10 uses dentures. None of the care plan goals were checked to indicate the goal was choosen for the resident. The care plan approaches included to monitor for oral/gum discomfort, notify physician promptly, and dental consult as ordered and as needed. A review of Resident 10's Dental Report dated December 4, 2017, indicated full upper and lower dentures were delivered. On February 21, 2018 at 7:35 a.m., during an interview, the Social Service Director (SSD) stated she notified the dentist and the dentist will be coming to see the resident. A review of the facility's undated policy and procedure titled "Care Plans-Comprehensive," indicated an interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. b. A review of the admission record indicated Resident 24 was admitted to the facility on May 26, 2017, with diagnoses that included Alzheimer's disease (a brain disorder that affects the parts of the brain that control thought, memory, and language). A review of Resident 24's Physician's Order dated May 26, 2017, indicated to admit the resident to hospice care. A review of the Nursing Facility/Hospice Collaboration Plan of Care dated May 30, 2017, indicated the frequency of visits included FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 9 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the hospice Registered Nurse (RN) to visit once every two weeks, one visit as needed, and the volunteer to visit once a month and one visit as needed. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 6, 2017, indicated Resident 24 had severely impaired cognitive skills for daily decision making. The MDS did not indicate hospice care was provided. On February 22, 2018 at 12:24 p.m., during an interview, Registered Nurse 2 (RN 2) stated the visits for the hospice RN and the volunteer were not implemented as indicated in the care plan. RN 2 was unable to provide documented evidence that the hospice RN had visited Resident 24. c. A review of the admission record indicated Resident 42 was admitted to the facility on November 10, 2017, with diagnoses that included Alzheimer's disease (is a brain disorder that affects the parts of the brain that control thought, memory, and language). A review of Resident 42's Physician's Order dated January 4, 2018, indicated to admit the resident to hospice care. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 5, 2018, indicated Resident 24 had severely impaired cognitive skills for daily decision making. The MDS indicated hospice care was provided. A review of the Nursing Facility/Hospice Collaboration Plan of Care dated January 9, 2018, indicated the frequency of visits included the hospice Registered Nurse (RN) to visit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 10 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE once every two weeks and one visit as needed. On February 22, 2018 at 12:24 p.m., during an interview, Registered Nurse 2 (RN 2) stated the visits for the hospice RN were not implemented as indicated in the care plan. RN 2 was unable to provide documented evidence that hospice RN had visited Resident 42. A review of the facility's undated policy and procedure titled "Care Plans-Comprehensive," indicated an interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. d. A review of Resident 21's admission record indicated the resident was admitted to the facility on May 16, 2017 and readmitted on July 3, 2017, November 21, 2017 and December 24, 2017, with diagnoses that included urinary tract infection (UTI, an infection of the kidney, ureter, bladder, or urethra) gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach), stroke, neurogenic bladder (dysfunction (flaccid or spastic) and Escherichia coli (E. Coli, a bacterium commonly found in the intestines of humans and other animals, where it usually causes no harm. If enters into urinary system can cause UTI). A review of Resident 21's History and Physical dated May 18, 2017 and July 4, 2017, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated May 20, 2017, indicated Resident 21 was severely impaired in cognition (mental processes) in daily decisionFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 11 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE making. Resident 3 was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toileting. The MDS indicated Resident 21 had a UTI upon admission. A review of Resident 21's Care Plan for UTI, Potential For Reoccurrence, due to Suprapubic Catheter (a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the tummy), initiated on May 17, 2017, indicated a goal to resolve UTI and prevent reoccurrence of infection. One of the interventions indicated was to administer medication as ordered and observe for any signs/symptoms of adverse reaction. The care plan did not specify the medication to be administered. The intervention indicated to encourage changes in position to prevent urinary stasis (period of inactivity). However, Resident 21 is unable to move by himself. The care plan intervention indicated to encourage fluids as tolerated to maintain adequate hydration. However, Resident 21 is unable to drink fluids. The care plan was not specific, person-centered and individualized to meet Resident 21's care needs. In addition, there were no interventions such as administration of cranberry juice, cranberry pill, or increase fluids above the normal recommended requirements, which are usually indicated for UTI prevention. A review of Resident 21's Care Plan goal for Prone to Develop UTI, due to Suprapubic Catheter, initiated on May 17, 2017, indicated the resident will have no signs/symptoms of hematuria (blood in urine), abdominal distention, urinary retention, high temperature every month for three months. The intervention indicated to monitor intake/output every shift and total every 24 hours. The intervention indicated to irrigate the catheter per physician's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 12 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE orders. A review of Resident 21's general acute care hospital (GACH) Infectious Disease Progress Report dated July 2, 2017, indicated the resident acquired a UTI with VRE (Vancomycin-resistant enterococci - a type of bacteria called enterococci that have developed resistance to many antibiotics) and ESBL (Extended spectrum beta-lactamases- a type of enzyme or chemical produced by some bacteria. ESBL enzymes cause some antibiotics not to work for treating bacterial infections), and E. coli to the urine. A review of Resident 21's Client Diagnosis Report indicated the E. coli was diagnosed on July 3, 2017. During an observation on February 20, 2017 at 7:50 a.m., Resident 21's suprapubic catheter was observed. Sediments were seen in the catheter tubing. Licensed Vocational Nurse 1 (LVN 1) observed this and stated sediments were to be expected because the resident has a suprapubic catheter. This was the only observation of Resident 21 during the survey. Resident 21 was discharged to the GACH the evening of February 20, 2017. Resident 21 did not return to the facility. A review of Resident 21's Physician Orders indicate the following: 1. Flush (cleanse) urinary catheter with 60 milliliters (ml) of Acetic Acid 0.25% solution every day as needed if clogged or urinary retention, dated May 16, 2017. 2. Flush feeding tube with 50 ml of water before and after administration of medication every shift, dated May 16, 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 13 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Flush feeding tube with 250 ml with 250 ml of water every shift, dated May 16, 2017. 4. Record intake and output every shift for thirty days, dated May 16, 2017. 5. Diabeticsource 1.2 calories at 80 ml per hour for 20 hours to provide 1600 ml/1920 Calories by G-Tube, dated May 16, 2017. 6. Diabeticsource 1.2 at 60 ml per hour for 20 hours, dated July 3, 2017. 7. Diabeticsource 1.2 at 65 ml per hour for 20 hours, dated August 25, 2017. 8. Contact isolation of extended spectrum beta lactimases (bacteria resistant to most betalactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam) and Vancomycin resistant enterococi (VRE, bacteria that is resistant to the antibiotic Vancomycin) of sputum and urine, dated July 3, 2017. 9. Ellura (a supplement made from 36 mg PAC extracted from cranberries and is used to prevent urinary tract infections) 36 milligrams (mg) by GT every day for UTI prophylaxis (taken to prevent disease) family to provide, dated October 24, 2017. On February 22, 2018 at 7:52 a.m., in an interview the Director of Nurses (DON) stated if Resident 21's urine output for the shift is below 600 ml the CNA will report and the suprapubic catheter will be flushed (cleansed with Acetic Acid 0.25% solution). A review of the CNA Daily Flow Sheet for December 2017, indicated there were at least eleven times when Resident 21's urine output was below 600 ml per shift, but the December FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 14 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2017, Treatment Administration Record (TAR) indicated the resident's catheter was flushed only 2 times instead of eleven times, as the physician ordered. During an interview with Registered Nurse 1 (RN 1) and the DON on February 22, 2018 at 7:52 a.m., when asked what is being done to prevent a reoccurrence of Resident 21's UTI, RN 1 stated she asks the nurses their concerns and asks the family what their concerns are for the Interdisciplinary Team (IDT-a coordinated group of experts from several different fields) meeting. RN 1 stated the IDT addressed concerns raised by Family Member 1. RN 1 was unable to provided a reason why the IDT did not provide any intervention/recommendation on UTI prevention. RN 1 stated, "We don't discuss anymore because Family Member 1 is aware. Family Member 1 knows that the patient has a recurrent UTI due to a condition." The DON stated staff are giving the resident fluids. The DON stated staff are flushing the suprapubic catheter not daily, but as needed per the physician order. The DON stated Resident 21 is receiving Ellura for UTI prophylaxis. The DON stated Ellura was not started until suggested by Family Member 1. The DON stated the Registered Dietician has not made any recommendations regarding increasing fluids when Resident 21 has an active UTI or to prevent UTI. When asked how Resident 21 acquired E. coli. in the urine when he was readmitted November 21, 2017, the DON did not provide an answer. The DON stated there needs to be more inservice training for cleaning the resident.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 03/21/2018 §483.21(b)(3) Comprehensive Care Plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 15 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the licensed nursing staff failed to observed standard of nursing practice for two of 17 sample residents (Residents 58, 63) by failing to: 1. Implement a landing mattress and to use bilateral side rails (Resident 58). 2. Follow-up and implement a physician order for a laboratory test for (Resident 63). These deficient practices had the potential to negatively affect the delivery of necessary care and services. Findings: a. A review of the admission record indicated Resident 58 was admitted to the facility on July 24, 2014, with diagnoses that included dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). A review of Resident 58's Physician's Order dated July 24, 2014, indicated to place bilateral side rails up for turning and reposition. A review of Resident 58's Physician's Order dated February 13, 2015, indicated to place landing mattress at bedside for fall risk precaution. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 16 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 9, 2018, indicated Resident 58 had moderately impaired cognitive skills for daily decision making. The MDS also indicated Resident 58 required total assistance from staff for bed mobility, transfer, toilet use, personal hygiene and bed bath. Bed rails were used daily. A review of Resident 58's Consent for Bedside Rail Use dated January 9, 2018, indicated bedside rails were ordered for the left and right upper bed side rails. On February 20, 2018 at 1:26 p.m., Resident 58 was observed awake and calm, lying in bed. There was one landing mattress on Resident 58's right side and bilateral upper and lower side rails were up. On February 20, 2018 at 1:45 p.m., during an interview, Registered Nurse 1 (RN 1) stated for Resident 58 staff should use only the upper left and right bedside rails. On February 21, 2018 at 10:30 a.m., during an interview, RN 1 stated Resident 58 should have a landing mattress on both sides of the bed. b. A review of the admission record indicated Resident 63 was admitted to the facility on October 23, 2017, with diagnoses that included dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 30, 2018, indicated Resident 63 had severely impaired cognitive skills for daily decision making. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 17 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE MDS indicated Resident 63 had physical behavioral symptoms directed toward others that included hitting, kicking, pushing, scratching, and grabbing that usually occurred four to six days. A review of Resident 63's Physician's Order dated February 18, 2018, indicated to do a lipid panel (a blood test that measures fats and fatty substances), CBC (a complete blood count is a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia.) CMP (comprehensive metabolic panel-a group of blood tests that provide an overall picture of your body's chemical balance and metabolism), Hgb (a protein in red blood cells that carries oxygen throughout the body) A1C (a test that measures the level of hemoglobin A1c in the blood as a means of determining the average blood sugar concentrations for the preceding two to three months), TSH (Thyroid Stimulating Hormone-a hormone that is secreted by the pituitary gland and stimulates the thyroid gland) to done on February 20, 2018. A review of Resident 63's laboratory/diagnostic request form dated February 20, 2018, with the Director of Nursing (DON) indicated the resident was agitated. A review of the Licensed Personnel Weekly Prosgress Notes dated from February 18, 2018 through February 22, 2018, did not indicate Resident 63 was agitated at the time of the laboratory blood draw. On February 22, 2018 at 11:45 a.m., during an interview, the DON stated the staff should have followed up again and the laboratory tests ordered were not done. A review of the revised facility policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 18 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE procedure dated October 2010, titled "Lab and Diagnostic Test Results - Clinical Protocol," indicated the staff will process test requisitions and arrange for tests.

F685 SS=D Treatment/Devices to Maintain Hearing/Vision CFR(s): 483.25(a)(1)(2)

F685 03/21/2018 §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility staff failed to ensure a resident received proper assistive devices to maintain hearing abilities by not assisting in arranging for audiologist referral consult for one of 17 sampled residents (Resident 10). This deficient practice resulted in a delay of services and Resident 10 not being able to hear adequately during a conversation. Findings: On February 20, 2018 at 8:40 a.m., Resident 10 was observed awake, alert, and calm lying in bed. During an interview, Resident 10 stated she was not able to hear well and she had reported her hearing problem to the doctor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 19 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the admission record indicated Resident 10 was admitted to the facility on November 24, 2016, with diagnoses that included muscle weakness. A review of Resident 10's Physician's Order dated November 24, 2016, indicated to provide the resident with an audiology consult and follow up as indicated. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated February 21, 2017, indicated Resident 10 had intact cognitive skills for daily decision making. The MDS indicated Resident 10 had adequate hearing. A review of the Otolaryngology/ENT (Ear, Nose, and Throat - specialist that treat residents with diseases and disorder of ear, nose and throat) Consult Report dated September 20, 2017, indicated Resident 10 complained of hearing difficulty and an audio referral was indicated. On February 21, 2018 at 7:35 a.m., during an interview, the Social Service Director (SSD) stated she called the physician's office and the office personnel stated they (the physician's office) failed to follow up with the recommendation. The SSD stated she should have followed up with the physician's office and to not rely on the physician's office.

F690 SS=G Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 03/21/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 20 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two of 17 sampled residents (Residents 21, and 66) who was at risk to develope urinary tract infection (UTI, an infection of the kidney, ureter, bladder, or urethra) was provided with care and services to prevent reoccurrences of UTI, including: 1. Failure to monitor Resident 21's intake and output for 30 days as ordered by the physician. 2. Failure to ensure Resident 21 who had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 21 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reoccurrence of UTI was assessed for additional fluid needs and ensure the resident received adequate fluids. 3. Failure to ensure Resident 21 received proper bowel incontinent care to prevent the suprapubic catheter from being contaminated with Escherichia coli in the urine (E. coli, a bacterium commonly found in the intestines of humans and other animals, where it usually causes no harm. If entering into the urinary system, this can cause UTI). 4. Failure to timely identify cause of Resident 21 reoccurences of UTI and update the plan of care with additional interventions to prevent further occurrences of UTI. As a result, by December 22, 2017, Resident 21 was transferred to General Acute Care Hospital (GACH) three times within seven months of admission to the facility with diagnoses that included sepsis and reoccurrences of UTI. Resident 66 was observed with the suprapubic catheter bag touching the floor and not anchored to the resident's thigh, which placed the resident at risk to acquire UTI. Findings: During an observation on February 20, 2017 at 7:50 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 21's suprapubic catheter (a hollow flexible tube that is inserted into the bladder through a cut in the tummy, used to drain urine from the bladder) was observed with sediments in the tubing. LVN 1 stated sediments were to be expected because the resident has a suprapubic catheter. A review of Resident 21's admission record indicated the resident was originally admitted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 22 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the facility on May 16, 2017 with diagnoses that included urinary tract infection, gastrostomy tube (GT, a tube inserted through the abdomen use for nutrition and medication administration directly to the stomach), and diabetes mellitus (high blood sugar). A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care-screening tool), dated May 20, 2017, indicated the resident's cognitive skills for daily decision-making were severely impaired and was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toileting. The MDS indicated the resident had an indwelling (a catheter inserted into the bladder that remains there to provide continuous urinary drainage) catheter and was incontinent (no control) of bowel. A review of Resident 21's Care Plan for UTI, Potential for Reoccurrence, due to suprapubic catheter, initiated May 17, 2017, indicated a goal to resolve UTI and prevent reoccurrence of infection. The interventions included to administer medication as ordered and observe for any signs/symptoms of adverse reaction, to encourage changes in position to prevent urinary stasis (period of inactivity), and to encourage fluids as tolerated to maintain adequate hydration. A review of Resident 21's physician's orders indicated the following: 1. Suprapubic catheter French (type of catheter) 18/5 milliliters (sterile water) to gravity drainage: Change monthly and as needed (PRN) if clogged, leaking, and pulled out, dated May 16, 2017. 2. Change urinary catheter drainage bag every two weeks, dated May 16, 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 23 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3. Flush (cleanse) urinary catheter with 60 milliliters (ml) of Acetic Acid 0.25 percent (%) solution every day as needed if clogged or urinary retention (the inability to completely or partially empty the bladder), dated May 16, 2017. 4. Monitor for sign and symptoms of UTI x 30 days. 1. Cloudy urine, 2. Foul odor, 3. Hematuria (Blood in urine), 4. Fever, 5. Abdominal distention (when substances, such as air (gas) or fluid, accumulate in the abdomen causing outward expansion), dated May 16, 2017. 5. Measure input and output every shift x 30 days, dated May 16, 2017. 6. Suprapubic site care, cleanse with normal saline (salt solution), pat dry, cover with dry dressing secure with paper tape daily. 7. Flush feeding tube with 250 ml of water every shift, dated May 16, 2017. 8. Flush feeding tube with 50 ml of water before and after administration of medication every shift, dated May 16, 2017. 9. Diabeticsource (feeding formula)1.2 at 80 ml per hour for 20 hours to provide 1600 ml/1920 Calories by G-Tube, dated May 16, 2017. A review of Resident 21's weekly Total Intake and Output (I&O) Record from May 16, 2017 to June 5, 2017, indicated the resident's average 24-hour fluid intake ranges from 1300 to 1960 ml. A review of Resident 21's physician's order dated June 6, 2017 at 2 p.m., indicated to give Gentamycin (antibiotic) 80 milligram (mg) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 24 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intramuscular (IM, an injection of a medication directly into muscle) every 12 hours for seven days for UTI. At 4 p.m., another order was received for oxygen at 10 liters per minute via mask continuously due to desaturation (low oxygen reading) and to transfer Resident 21 to General Acute Care Hospital (GACH) via 911 (paramedics emergency phone number). A review of Resident 21's GACH Progress Note, dated July 2, 2017, indicated the impression was sepsis (a potentially lifethreatening complication of an infection) due to pneumonia - Extended Spectrum Beta (ß) Lactamase (ESBL, enzymes produced by many species of bacteria which destroy one or more antibiotics) and pseudomonas (a bacterium), and UTI - vancomycin resistant enterococcus (VRE, type of bacteria called enterococci that have developed resistance to many antibiotics, especially Vancomycin) and E. coli to the urine. Resident 21 was admitted to GACH and treated with IM antibiotics. Resident 21 returned to the facility on July 3, 2017, with diagnoses that included UTI, Escherichia coli. A review of Resident 21's care plan for prone to develop UTI infection due to suprapubic catheter initiated on July 21, 2017 and reviewed on August 28, 2017, indicated the interventions included offer/encourage fluid intake and monitor intake and output every shift. A review of Resident 21's physician's orders indicated the following: 1. Suprapubic catheter French 18/5 milliliters to gravity drainage: Change monthly and as needed (PRN) if clogged, leaking, and pulled out, dated July 3, 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 25 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Change urinary catheter drainage bag every two weeks, dated July 3, 2017. 3. Flush urinary catheter with 60 milliliters (ml) of Acetic Acid 0.25 percent (%) solution every day as needed if clogged or urinary retention, dated July 3, 2017. 4. Monitor for sign and symptoms of UTI x 30 days. 1. Cloudy urine, 2. Foul odor, 3. Hematuria (Blood in urine), 4. Fever, 5. Abdominal distention, dated July 3, 2017. 5. Measure input and output every shift x 30 days, dated July 3, 2017. 6. Diabeticsource 1.2 at 60 ml per hour for 20 hours, dated July 3, 2017. 7. Flush feeding tube with 250 ml of water every shift, dated July 3, 2017. 8. Flush feeding tube with 50 ml of water before and after administration of medication every shift, dated July 3, 2017. 9. Contact isolation of ESBL and VRE of sputum (saliva and mucus coughed up) and urine, dated July 3, 2017. 10. Ellura (a supplement used to prevent urinary tract infections) 36 (mg by GT every day for UTI prophylaxis (taken to prevent disease), dated October 24, 2017. A review of Resident 21's weekly Total Intake and Output (I&O) Record from July 16, 2017 to July 30, 2017, indicated the resident's average 24-hour fluid intake ranged from 2000 to 2500 ml. There was no I&O recorded from July 3 to July 16, 2017, and no weekly I&O evaluation from July 31, 2017 to August 6, 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 26 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 21's Nutritional Assessment dated August 24, 2017, September 28, 2017, and October 31, 2017, indicated the estimated fluid need was approximately 2000 ml, tube feeding total fluids 1061 cc plus add the total GT flushes. On February 21, 2018 at 3:41 p.m., during an interview and review of Resident 21's medical record with the Director of Nurses (DON), the DON was not able to provide the I&O record from July 3 2017 to July 15, 2017. The DON was not able to provide documentation that the resident's UTI plan of care interventions were updated to prevent reoccurrences of UTI. There was no documentation that the Registered Dietitian addressed Resident 21's frequent UTI and the fluid need was reassessed. A review of Resident 21's physician's order dated November 13, 2017 at 1:08 p.m., (second transferred to GACH in six months) indicated to transfer Resident 21 to GACH via 911 due to altered level of consciousness. A review of Resident 21's Urine Culture, obtained November 14, 2017, before the resident was discharged to the GACH, indicated there was Escherichia coli in the urine. A review of Resident 21's GACH Progress Note dated November 15, 2017, indicated the assessment was sepsis secondary to complicated UTI (indwelling suprapubic catheter). A review of Resident 21's Emergency Department Note dated November 15, 2017 at 7:41 p.m., indicated Resident 21 was admitted to the emergency room for altered level of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 27 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE consciousness and rectal temperature of 37.9 Centigrade (100.2 Fahrenheit) (An average normal rectal temperature is 99.6°F (38°C). A review of Resident 21's Urine Culture, obtained November 21, 2017, indicated the resident had E. coli. /ESBL present in the urine. Resident 21 was admitted to GACH and treated with IM antibiotics and returned to the facility on November 21, 2017 with diagnoses that included UTI, VRE of urine. The resident had a physician's order dated November 21, 2017 for suprapubic catheter care, I&O, GTF flushes with 250 ml of water every shift, flush feeding tube with 50 ml of water before and after administration of medication every shift and Ellura medication as UTI prophylaxis. A review of Resident 21's Care Plan for UTI, Potential for Reoccurrence, due to suprapubic catheter, dated November 21, 2017, indicated a goal to resolve UTI and prevent reoccurrence of infection. The interventions included to administer medication as ordered and observe for any signs/symptoms of adverse reaction, to encourage changes in position to prevent urinary stasis, and to encourage fluids as tolerated to maintain adequate hydration. A review of Resident 21's Nutritional Assessment dated December 2, 2017 and January 21, 2018, indicated fluid requirements were approximately 2000 ml total. A review the Interdisciplinary Team Conference Record for May 22, 2018, July 12, 2017, September 5, 2017, and December 6, 2017, indicated Resident 21 was incontinent and had a suprapubic catheter but there was no interventions discussed to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 28 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reoccurrence of UTI. A review of Resident 21's Licensed Personnel Weekly Progress Notes dated December 22, 2017, indicated the resident was transferred to GACH with fever. A review of Resident 21's GACH consultation report dated indicated has had recurrence UTI due to his indwelling catheter. The resident was readmitted back to the facility on December 24, 2014. On February 22, 2018 at 7:52 a.m., during an interview with Registered Nurse 1 (RN 1) and the DON, both were unable to provide a reason why the IDT did not provide any intervention/recommendation on UTI prevention. The DON stated the Registered Dietician has not made any recommendations regarding increasing fluids when Resident 21 has an active UTI or as a preventative measure to prevent UTI. When asked how Resident 21 acquired E. coli to the urine when he was readmitted November 21, 2018, the DON did not provide an answer. The DON stated that there needs to be more inservice training on cleaning the resident. b. A review of Resident 66's admission record indicated the resident was admitted on November 8, 2016 and readmitted July 17, 2017, with diagnoses that included urinary tract infection (UTI, an infection of the kidney, ureter, bladder, or urethra), stroke, and neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition.) A review of Resident 66's Minimum Data Set (MDS, a comprehensive assessment and carescreening tool), dated February 3, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 29 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated Resident 66 was moderately impaired in cognition (mental processes) in daily decision-making. Resident 3 was totally dependent on two persons for bed mobility, and one person total dependence for transfer, dressing, eating, and toileting. A review of Resident 66's Physician Orders indicated the following: 1. Cranberry juice 8 ounces by mouth three times a day with meals for UTI prophylaxis, dated July 17, 2017. 2. Cranberry pill 450 mg by mouth twice a day for UTI prophylaxis, dated January 19, 2018. 3. Flush suprapubic catheter with acetic acid 0.25%, 60 ml every day for foley care, dated July 17, 2017. 4. Flush suprapubic catheter with acetic acid 0.25%, 60 ml as needed if catheter is clogged or obstructed, dated July 17, 2017. A review of Resident 66's Care Plan for Recent UTI, initiated April 5, 2017, indicated a goal to resolve UTI and prevent reoccurrence of infection. One of the interventions was to administer medications as ordered and observe for any signs/symptoms of adverse reaction. However, the medications to observe for are not indicated. During an observation on February 22, 2018 at 11:38 a.m., Resident 66's suprapubic catheter bag was touching the floor and the suprapubic catheter was not anchored to prevent unnecessary pulling which can result in catheter dislodgement. A review of the Fundamentals of Nursing, copyright 2004, p. 1277 , "Implementation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 30 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Foley Catheter", indicates the catheter bag should be taped to the inside of a female client's thigh or for a male, to tape the catheter to the thigh or abdomen of a male client. A review of the facilities policy and procedure revised October 2012, for UTI indicated signs and symptoms to monitor for. However, there were no interventions specified for prevention of UTI.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 03/21/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 31 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is 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. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of 17 sampled residents (Residents 24) by failing to: 1. Monitor specific behavior manifestation related to the resident's delusion that staff will hurt the resident and monitor the episodes of behavior according to the prescribed antipsychotic (medication used to treat severe mental illness) medication dose ordered. 2. Evaluate for the effectiveness and/or ineffectiveness of Zyprexa-an antipsychotic medication, before increasing the dose of the medication instead of considering a gradual dose reduction (GDR) of the medication. These deficient practices had the potential to result in over use of an antipsychotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 32 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse drug reactions. Findings: A review of the admission record indicated Resident 24 was admitted to the facility on May 26, 2017, with diagnoses that included Alzheimer's disease (a brain disorder that affects the parts of the brain that control thought, memory, and language) and brief psychotic disorder (a sudden, short-term display of psychotic behavior, such as hallucinations or delusions). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 6, 2017, indicated Resident 24 had severely impaired cognitive skills for daily decision making. A review of Resident 24's Physician's Order indicate the following: 1. May 26, 2017 - Zyprexa 2.5 milligram (mg) by mouth daily for psychosis manifested by paranoia (the perception or suspicion that others have hostile or aggressive motives in interacting with them) that staff will hurt her (resident). 2. June 18, 2017 - discontinue Zyprexa 5 mg every morning and 2.5 mg at bedtime by mouth. Zyprexa 5 mg every morning and at bedtime for psychosis manifested by paranoia that staff will hurt her (resident). 3. July 28, 2017 - Zyprexa 10 mg in the morning and 5 mg at bedtime for psychosis manifested by paranoia that staff will hurt her (resident). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 33 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 24's Psychotropic Summary Sheet initiated on June 2, 2017, indicated the following: 1. From June 2, 2017 to June 15, 2017, indicated a total of two episodes and to continue medication. 2. From June 16, 2017 to July 19, 2017, indicated a total of 13 episodes and to continue medication. 3. From July 20, 2017 to August 17, 2017, indicated a total of 8 episodes and to continue medication. 4. From August 18, 2017 to September 14, 2017, indicated zero episodes and to continue medication. 5. From September 15, 2017 to October 19, 2017, indicated zero episodes and to continue medication. 6. From October 20, 2017 to November 23, 2017, indicated zero episodes and to continue medication. 7. From November 24, 2017 to December 21, 2017, indicated zero episodes and to continue medication. 8. From December 22, 2017 to January 25, 2018, indicated zero episodes and to continue medication. On February 23, 2018 at 2:30 p.m., during an interview, Registered Nurse 1 (RN 1) stated she was not aware Resident 24's Psychotropic Summary Sheet was not updated with the latest dosage changed on July 28, 2017, and that the monitoring did not reflect the specific medication dose to ensure the effectiveness of the new dose ordered. A review of Resident 24's Interdisciplinary Team (IDT-a coordinated group of experts from several different fields ) Resident's Person Centered Care Conference Record on June 6, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 34 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2017, September 11, 2017, and December 14, 2017, indicated behavior and psych medications were reviewed and discussed. There was no recommendation made or discussion indicated regarding GDR. A review of Resident 24's Consultant Pharmacist Progress Notes indicated the Pharmacist conducted a drug regimen reviewed every month from June 2017 to February 2018. On February 23, 2018 at 4:10 p.m., during an interview, Pharmacist 1 when asked about Resident 24's decreased episodes of behavior from July 20, 2017, of eight episodes until January 25, 2018, and of zero episodes for five months consecutively, was GDR recommended or attempted, Pharmacist 1 stated no and the medication was most likely overlooked. On February 27, 2018 at 10:00 a.m., during an interview RN 2, when asked what specific behavior did Resident 24 exhibit when the resident was experiencing paranoia that staff will hurt her, RN 2 stated the resident mumbled, was scared of staff that she did not know, or she grabbed or pushed staff away even when she was unprovoked, and resident was backing away from family. RN 2 stated there should be monitoring for the specific behavior. RN 2 stated the Pharmacist was not part of the IDT meetings and GDR was not discussed. A review of Resident 24's Anti-Psychotic Medication care plan goals initiated on December 3, 2017, for a resident that has episodes of psychosis manifested by paranoia that staff will hurt her included that the resident will not have more than two episodes of psychosis. The approaches included to monitor and document number of behavioral FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 35 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE episodes every shift, to monitor response to medication as indicated, to assess the potential cause of reason for the behavior, to evaluate the effectiveness and side effects of medication for possible reduction/discontinuation of medication, and notify physician as needed. A review of the facility's policy and procedure revised date of April 2007, titled "Pharmacy Services - Role of the Consultant Pharmacist," indicated the Consultant Pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including participating on the interdisciplinary team to address and resolve medication-related needs or problems. The Consultant Pharmacist will provide specific activities related to medication regimen review including appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services including medication irregularities, and pertinent resident-specific documentation in the medical record as indicated.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 03/21/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility staff failed to ensure that it is free of medication error rate of five percent or greater as evidenced by the identification of two medication errors out of 25 opportunities, to yield a facility medication error rate of 8 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 36 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE percent. The Licensed Nurse failed to administer the full dosage of the medications by gastrostomy tube (GT- a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and to administer medications by GT instead of by mouth for 1 of seventeen sampled residents (Resident 41). These deficient practices resulted in placing the resident at risk for receiving less medication than was ordered by the physician and resulted in administering medication by the wrong route. Findings: a1. A review of the admission record indicated Resident 41 was admitted to the facility on September 23, 2017, with diagnoses that included gastrostomy. A verification of the medication administered with Resident 41's Physician's Order for September 23, 2017, indicated the following: 1. Metoprolol tart 12.5 milligram (mg) via GT two times a day for high blood pressure, hold for systolic blood pressure (SBP-the maximum arterial pressure during contraction of the left ventricle of the heart) less than 110 mercury and heart rate less than 60. 2. Multivitamin and minerals liquid 5 milliliters (ml) via GT daily for supplement. 3. DSS (docusate sodium) 100 mg via GT daily for constipation hold for loose stools. 4. Eliquis 5 mg via GT daily for atrial fibrillation (irregular heart beat). 5. ASA (aspirin) 81 mg via GT daily for CVA (cerebrovascular accident or stroke) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 37 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prophylaxis (prevention). For October 23, 2017, Resident 41's Physician's Orders indicated the following: 6. Enalapril 5 mg GT two times a day for high blood pressure, hold for systolic blood pressure below 110 mercury. For November 15, 2017, Resident 41's Physician's Orders indicated the following: 7. Reglan 10 mg oral three times a day for gastroesophageal reflux disease (GERD). On February 21, 2018 at approximated 7:55 a.m., during a medication pass observation, Licensed Vocational Nurse 2 (LVN 2) did not rinse Resident 41's medicine cups with water for six out of seven medication cups to ensure the crushed medications were not left in the cups. On February 21, 2018 at 8:40 a.m., during an interview, LVN 2 stated he should rinse each cup with water to make sure all the medications were given. a2. A review of Resident 41's Physician's order dated February 19, 2018, indicated: 1. Discontinue crushing all her meds and give GT. 2. Crush all her meds, mix with apple sauce and give by mouth per patient's request. On February 23, 2018 at 1:30 p.m., during an interview, LVN 2 stated he was not aware there was an order for Resident 41 to discontinue medication administration via GT and to administer medication by mouth. A review of the facility's undated policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 38 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE procedure titled "Enteral Tube Medication Administration," indicated the medication cup is rinsed with water to get all of the medication.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 03/21/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to: 1. Have a system of monitoring the temperature in medication storage areas (cabinets) in Nurses' Station 1 and Station 2 for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 39 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE two out of two medication storage areas. 2. Ensure medications requiring refrigeration were stored at proper temperature 36-46 degrees Fahrenheit (°F) in Station 2. 3. Ensure the temperature for the refrigerator, where medications are stored was monitored and recorded consistently in Station 2. 4. Ensure Emergency Kit (E-Kit) was replaced within 72 hours in Station 2. 5. Ensure documentation of medication removed from the E-Kit was recorded in Station 1. 6. Ensure medications from the E-Kit are used for the residents and not for staff in Station 1. This had a potential for the residents to receive medications with improper efficacy due to improper storage condition of medications stored outside the required room temperature range and potential to result in an insufficient amount of medications on hand in case of emergency and the potential to result in the inability to identify drug diversion readily. Findings: On February 20, 2018 at 8:40 a.m., during an observation of the medication storage area in Nurse's Station 2, there were house supply medications stored in the cabinet, the E-Kit had a red tag, and there was no thermometer in the Nurse's Station medication storage areas. A review of the Nurse's Station 2 Emergency Kit Sign-Out Log indicated on February 12, 2018, was the last time an entry was recorded that the medication was removed from the EKit. A review of Nurse's Station 2 Pharmacy Order Sheet dated February 18, 2018, indicated a request for oral E-Kit replacement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 40 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On February 20, 2018 at 8:50 a.m., during an interview, Registered Nurses 2 (RN 2) stated the red tag on the E-Kit meant the E-Kit was opened and pharmacy was notified on February 18, 2018 (six days after the medication was removed), but no one followed up to ensure a new E-Kit was delivered within 72 hours. RN 2 stated she was not aware that there should be a thermometer in the Nurse's Station to monitor the temperature of the medications stored in the cabinet. On February 20, 2018 at 9:10 a.m., an observation of the medication storage area in Nurse's Station 1, there were house supply medications stored in the cabinet, the E-Kit had a red tag, and there was no thermometer in the Nurse's Station. On February 20, 2018 at 9:12 a.m., during an interview, the Director of Nursing (DON) stated somebody took out medications from Nurse's Station 1 E-Kit and did not document the removal of the medication. A review of the Emergency Kit Sign-Out Log for Nurse's Station 1 with the DON, indicated the E-Kit was last replaced on January 29, 2018. A review of Nurse's Station 1 Pharmacy Order Sheet dated February 15, 2018, indicate a request for the E-Kit replacement. On February 20, 2018 at 9:15 a.m., the DON called the pharmacy and stated the E-Kit was replace on February 15, 2018, at night and was open again for an employee's use on February 17, 2018. On February 20, 2018 at 9:20 a.m., the DON performed an inventory count and found five of six tablets of Azithromycin (antibiotic medication) were missing from the E-Kit and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 41 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated the staff are not suppose to take medications from the E-Kit for themselves or for another staff member, it is for the residents' use only. On February 20, 2018 at 9:30 a.m., the DON stated she was not aware that there should be a thermometer in the Nurse's Station to monitor the temperature of the medications stored in the cabinet. On February 20, 2018 at 9:48 a.m., the refrigerator that stored the medications in Station 2 was inside a cabinet and was observed to have a temperature of 50 degrees Fahrenheit (°F). A review of the Refrigerator Control Log for the month February 2018, indicated February 15, 16, and 20, did not have a temperature recorded. On February 20, 2018 at 9:50 a.m., during an interview, the DON stated the temperature should be between 36 to 46 °F. On February 20, 2018 at 4:35 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she received a text from another employee (LVN 5) requesting for Z-pack (Azithromycin antibiotic medication) from the pharmacy. LVN 4 stated the pharmacy suggested to take the medication from the EKit and will deliver the new E-Kit the next day. A review of the facility's undated policy and procedure titled "Storage of Medications," indicated medications requiring storage at "room temperature" are kept at temperatures ranging from 59 °F to 86 °F. Medications requiring "refrigeration" or "temperatures between 36 °F and 46 °F" are kept in a refrigerator with a thermometer to allow FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 42 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE temperature monitoring. A review of the facility's undated policy and procedure titled "Emergency Pharmacy Service and Emergency Kits," indicated the nurse records the medication use on the Emergency Kit Sign-Out Log and Drug Use Form. Fax or call the pharmacy for the order and for the replacement. A log book must be maintained showing use of supply. If exchanging kits, opened kits are replaced with sealed kits within (72 hours) of opening.

F849 SS=E Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 03/21/2018 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 43 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 44 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 45 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 46 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for two of 17 sample resident (Resident 24 and 42), by failing to: 1. Provide skilled nursing services (hospice licensed nurse) as ordered by the hospice physician (Resident 42). 2. Provide skilled nursing services (hospice licensed nurse and volunteer) as ordered by the hospice physician (Resident 24). 3. Ensure that the hospice licensed nurses will visit according to the hospice calendar provided to the skilled nursing facility (Resident 24 and 42). 4. Collaborate with hospice representatives to ensure the hospice plan of care was implemented (Resident 24 and 42). 5. Ensure there is a designated staff to coordinate the care and services provided by the hospice and the facility (Resident 24 and 42). These deficient practices had the potential to result in a delay or lack of coordination in delivery of hospice care and services to residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 47 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: a. A review of the admission record indicated Resident 24 was admitted to the facility on May 26, 2017, with diagnoses that included Alzheimer's disease (a brain disorder that affects the parts of the brain that control thought, memory, and language). A review of Resident 24's Physician's Order dated May 26, 2017, indicated to admit the resident to hospice care. A review of Resident 24's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 6, 2017, indicated the resident had severely impaired cognitive skills for daily decision making. The MDS did not indicate hospice care was provided. A review of the IDG (Interdisciplinary Group) Case Conference Calendar for year 2018, indicated the meetings are held every other Tuesday since January 9, 2018. A review of Resident 24's Hospice POC (Plan of Care) Summary dated February 6, 2018, indicated the frequency of visits included the hospice Registered Nurse (RN) to visit once every two weeks and one visit as needed and the volunteer to visit once a month and one visit as needed. A review of Resident 24's Nursing Facility/Hospice Collaboration Plan of Care dated February 12, 2018, indicated the frequency of visits included the hospice Registered Nurse (RN) to visit once every two weeks and one visit as needed and the volunteer to visit once a month and one visit as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 48 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 24's hospice calendar for February 2018, did not indicate visits for the hospice RN and the volunteer. On February 22, 2018 at 12:24 p.m., during an interview, Registered Nurse 2 (RN 2) stated she was unable to provide documented evidence of when the hospice RN and volunteer visited the resident, there was no sign in sheet to ensure the services were provided as ordered, the calendar did not include the hospice RN and volunteer visit schedule, and the IDG meetings report were not provided to the facility for communication between the facility staff and hospice regarding Resident 24's care. On February 22, 2018 at 4:30 p.m., during an interview, the Director of Nursing stated the facility does not have a designated staff to coordinate the care with the hospice provider to ensure the care and services were provided by the hospice and the facility. A review of the hospice and facility contract indicated the hospice will assume full responsibility for the scheduling of visits and/or hours that the patient is to be seen by those visiting the client. Under the section title "Interdisciplinary Group Care Conferences" indicated hospice will document communications with skilled nursing facility to ensure that the patient's needs are addressed and met 24 hours a day. b. A review of the admission record indicated Resident 42 was admitted to the facility on November 10, 2017, with diagnoses that included Alzheimer's disease (a brain disorder that affects the parts of the brain that control thought, memory, and language). A review of Resident 42's Physician's Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 49 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated January 4, 2018, indicated an order to admit the resident to hospice care. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 5, 2018, indicated Resident 42 had severely impaired cognitive skills for daily decision making. The MDS indicated hospice care was provided. A review of the IDG (Interdisciplinary Group) Case Conference Calendar for year 2018, indicated the meetings are held every other Tuesday since January 9, 2018. A review of Resident 42's Nursing Facility/Hospice Collaboration Plan of Care dated January 9, 2018, indicated the frequency of visits included the hospice Registered Nurse (RN) to visit once every two weeks and one additional visit as needed. A review of Resident 42's Hospice POC (Plan of Care) Summary dated February 6, 2018, indicated the frequency of visits included the hospice Registered Nurse (RN) to visit once every two weeks and one additional visit as needed. A review of Resident 42's Hospice calendar for February 2018, did not indicate visits for the hospice RN. On February 22, 2018 at 12:24 p.m., during an interview, Registered Nurse 2 (RN 2) stated she was unable to provide documented evidence of when the hospice RN visited the resident, there was no sign in sheet to ensure the services were provided as ordered, the calendar did not include the hospice RN schedule, and the IDG meetings report was not provided to the facility for communication between the facility staff and hospice regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 50 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 42's care. On February 22, 2018 at 4:30 p.m., during an interview, the Director of Nursing stated the facility does not have a designated staff to coordinate the care with the hospice provider to ensure the care and services was provided by the hospice and the facility. A review of the hospice and facility contract indicated hospice will assume full responsibility for the scheduling of visits and/or hours that the patient is to be seen by those visiting the client. The contract section titled "Interdisciplinary Group Care Conferences" indicated hospice will document communications with skilled nursing facility to ensure that the patient's needs are addressed and met 24 hours a day.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 04/11/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 51 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 52 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility staff failed to observe infection control measures for one of 17 sampled residents (Resident 10) and for one of two randomly selected residents (RSR 65) by failing to sanitize the sphygmomanometer (equipment used to measure blood pressure) cuff between resident's (Resident 10) and by failing to wash hands between medication administration (Resident 10 and RSR 65). These deficient practices compromised infection control measures to prevent the potential spread of infections. Findings: On February 20, 2018 at 7:57 a.m., during a medication pass observation, Licensed Vocational Nurse 2 (LVN 2) stated he had finished with the medication administration for Resident 41. LVN 2 went to Resident 10's room and started to check the resident's blood pressure with the sphygmomanometer. LVN 2 did not wash his hands after the administration of Resident 41's medication. LVN 2 did not sanitize the blood pressure cuff before and after use or between the residents. On February 20, 2018 at 8:40 a.m., during an interview, LVN 2 stated he should wash his hands before and after medication administration and sanitize the blood pressure cuff before and after each resident's use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 53 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On February 20, 2018 at 8:47 a.m., during a medication pass observation, LVN 3 was documenting in the Medication Administration Record (MAR) after the medication administration to a Randomly Selected Resident 9 (RSR 9). LVN 3 proceeded to RSR 65's for her next medication administration. LVN 3 did not wash her hands after the administration of RSR 9's medication and the start of the medication administration for RSR 65. On February 20, 2018 at 9:43 a.m., during an interview, LVN 3 stated she thought she used gel (alcohol base) on her hands before and after medication administration. A review of the facility's undated policy and procedure titled "Handwashing," indicated appropriate ten to fifteen seconds handwashing must be performed under the following conditions that included before preparing or handling medications, after handling items potentially contaminated with any resident's blood, excretions, or secretions, and upon completion of duty.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to meet the required room size of 80 square feet for 15 of 28 resident rooms in multiple resident bedrooms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 54 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident. Findings: During the general observation of the facility from February 20, 2018 to February 27, 2018, the facility had rooms that measured less than 80 square feet per resident in multiple residents' bedroom. A review of the Client Accommodations Analysis indicated the following: Room No: Room Sq. Footage: Resident Capacity: Square Ft. Per 1 156 2 78 2 156 2 78 7 228 3 76 8 228 3 76 9 228 3 76 10 228 3 76 11 228 3 76 12 228 3 76 14 228 3 76 15 228 3 76 16 228 3 76 17 228 3 76 18 228 3 76 19 228 3 76 21 228 3 76 A review of the facility's request for Room Size Waiver dated February 23, 2018, indicated a request for room waiver for Rooms 1, 2, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, and 21. The waiver letter indicated there is still enough space to provide for each resident's care, dignity and privacy. The rooms are in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 55 of 56 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 02/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accordance with the special needs of residents and will not have an adverse effect on the residents' health and safety or impeded the ability of any resident in the room to attain his/her highest practicable well-being. During the observation from February 20, 2018 through February 27, 2018, there was ample space to provide care to the residents in the rooms, and ample space to move freely inside the rooms. During the Group Interview on February 21, 2018 at 11:00 a.m., alert residents did not have any issues with their room size. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JR6011 Facility ID: CA920000030 If continuation sheet 56 of 56