Other·October 14, 2019

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 the concurrent EXTENDED RECERTIFICATION and ABBREVIATED surveys to investigate COMPLAINT No. CA00652152. Representing the California Department of Public Health: Surveyor 37689, HFEN; Surveyor 38660, HFEN; Surveyor 40483, HFEN; and Surveyor 41324, HFEN. FOR COMPLAINT No. CA00652152: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION AND FOUND NO VIOLATION TO THE REGULATIONS. The surveyors entered the facility on 9/3/19 at 0730 hours. The census was 38. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADCS/ADON - Assistant Director of Clinical Services ADL - activities of daily living Bi-PAP/CPAP - bi-level or constant positive airway pressure (used to treat obstructive sleep apnea CAI - community acquired infection (an infection present prior to admission to the facility or developed within 48 hours of admission) CDC - Centers for Disease Control and Prevention CDM - Certified Dietary Manager cfu/ml - colony-forming unit per milliliter cm - centimeter(s) CNA - Certified Nursing Assistant DCS - Director of Clinical Services 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: 3N6711 Facility ID: CA0600001680 If continuation sheet 1 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 DSD - Director of Staff Development GT - gastrostomy tube (a tube inserted through the abdominal wall into the stomach, used for feeding and/or administering medications) HAI - healthcare associated infection (an infection developed 48 hours after admission to the facility) IDT - Interdisciplinary Team LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) ml - milliliter(s) OT - Occupational Therapy P&P - policy and procedure PICC - peripherally inserted central catheter POLST - Physician Orders for Life-Sustaining Treatment RD - Registered Dietitian RN - Registered Nurse Roho cushion - (brand name of an adjustable, air-filled wheelchair support surface used for pressure relief) SBAR - Situation, Background, Assessment, Recommendation (communication model) SSD - Social Services Director Supra-pubic catheter - a surgical inserted catheter placed through the lower abdomen into the bladder to drain urine

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 09/24/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 2 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to promote dignity and respect for one of 12 final sample residents (Resident 332). The facility failed to provide privacy to Resident 332 during a dressing change procedure. This failure led to Resident 332 feeling upset and posed a risk to the resident's physical and emotional wellbeing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 3 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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: On 9/9/19 at 0942 hours, an observation was conducted of a PICC line measurement and dressing change with RN 1. RN 1 was observed not providing privacy to Resident 332 by closing the door or pulling the privacy curtain during the PICC line measurement and dressing change. On 9/9/19 at 1006 hours, an interview was conducted with Resident 332. When asked how it made her feel receiving a treatment with no privacy, Resident 332 stated she felt uncomfortable with both the open door and open privacy curtain during the procedure. Resident 332 stated she did not like the open curtain because anyone passing by her room could see into her room. Resident 332 stated she used to be terribly shy, but one could not be shy here. Resident 332 stated she would have felt better if the staff had closed the privacy curtain. Medical Record Review for Resident 332 was initiated on 9/9/19. Resident 332 was admitted to the facility on 8/22/19. Review of Resident 332's MDS dated 9/2/19, showed the resident was cognitively intact. On 9/9/19 at 1012 hours, an interview was conducted with RN 1. RN 1 verified she did not close the privacy curtain or the door while performing the dressing change procedure for Resident 332. mmHg

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 09/24/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 4 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 5 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 failed to obtain a copy of an advance directive for inclusion in the medical record for two of 12 final sampled residents (Residents 3 and 25). This had the potential for the residents' advanced care planning decisions regarding their health care and treatment options not being honored. Findings: 1. Medical record review for Resident 3 was initiated on 9/3/19. Resident 3 was admitted to the facility on 6/3/19. Review of the admission MDS dated 6/10/19, showed Resident 3 had no cognitive impairment. Review of Attachment G - Advance Directives Policy and Record dated 6/4/19, showed the facility was made aware Resident 3 had an advance directive. Review of the POLST dated 6/5/19, Section D (Information and Signatures) showed no advance directive was checked off. Review of Resident 3's medical record failed to show a copy of Resident 3's advance directive was obtained or an attempt was made to obtain Resident 3's advance directive. On 9/5/19 at 0902 hours, an interview and concurrent medical record review was conducted with the SSD and the Admissions Coordinator. The SSD and the Admissions Coordinator verified the above findings. The Admissions Coordinator stated she was responsible for completing Attachment G, which was part of the admission packet, upon admission, then social services was to follow up for the copy of the advance directive. The SSD was unable to provide documentation she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 6 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 requested a copy of Resident 3's advance directive. 2. Medical record review for Resident 25 was initiated on 9/3/19. Resident 25 was admitted to the facility on 7/22/19. Review of the admission MDS dated 7/29/19, showed Resident 25 had no cognitive impairment. Review of Attachment G - Advance Directives Policy and Record dated 7/23/19, showed the facility was made aware Resident 25 had an advance directive. Review of the POLST dated 7/22/19, Section D (Information and Signatures) showed no advance directive was checked off. Review of Resident 25's medical record failed to show a copy of Resident 25's advance directive was obtained or an attempt was made to obtain Resident 25's advance directive. On 9/5/19 at 0914 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the above findings and stated she needed to call Resident 25's family member to provide the facility with a copy of the advance directive.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 09/24/2019 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 7 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 record review, the facility failed to ensure one of 12 final sampled residents (Resident 21) who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. This failure to provide the necessary care posed a risk to Resident 21's nutritional status and negatively impact the resident's psychosocial well-being. Findings: On 9/3/19 at 0825 hours, during the facility's initial tour, Resident 21 was observed having breakfast in bed. Resident 21's right arm was amputated and the resident was cutting a pancake with her left hand using a fork. Resident 21 was observed having difficulty cutting the pancake and putting a piece of pancake into her mouth. The pancake fell off her fork many times. Medical record review for Resident 21 was initiated on 9/3/19. Resident 21 was admitted to the facility on 3/19/13, and readmitted on 8/10/19, with the right upper arm amputation. Review of the MDS dated 8/17/19, showed Resident 21 was cognitively intact. Review of the Nutrition Risk Review dated 8/10/19, under Section M, showed Resident 21 required assistance with meals related right arm amputation. Review of Resident 21's OT Evaluation and Plan of Treatment dated 8/12-10/6/19, section Self Care Performance Assessment, showed the resident needed partial/moderate assistance with eating. Review of Resident 21's care plan failed to show a care plan problem to address Resident 21 with right upper arm amputation, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 8 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 555763 09/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 needed assistance with meals. On 9/3/19 at 1234 hours, Resident 21 was observed having lunch in bed with a family member at the bedside. The family member stated Resident 21 had a problem holding the fork, she kept dropping the fork, and had difficulty picking up the meat with the fork. The lunch tray was observed with a whole piece of chicken. The family member stated he cut the meat for Resident 21, the nursing staff just dropped the tray, and should had cut the meat for Resident 21. Resident 21 was observed picking up the meat using a fork with her left hand. When she tried to put a piece of chicken into her mouth, the chicken or the fork dropped back onto the tray or in bed. Resident 21 could not hold the fork tight, and had difficult feeding herself. The RD was called to Resident 21's room. The RD stated Resident 21 needed assistance with meals, and the staff should had helped cut her foods when they delivered the tray. The RD stated Resident 21's family member was always there to help resident 21. On 9/5/19 at 1448 hours, an interview and concurrent medical record review was conducted with the CDM regarding eating assistance for Resident 21. The CDM showed Resident 21's lunch ticket with the instruction to "assist with meals, for cutting food." The CDM stated, when delivering the tray, the CNAs should have looked at the lunch ticket to know how to assist the residents. On 9/6/19 at 0830 hours, an observation was conducted with Resident 21. Resident 21 was observed eating in bed by herself. Resident 21 had some milk and oatmeal. The tray was observed with scramble eggs, two pieces of bacon, and two toast halves. CNA 2 was called to Resident 21's room and asked how she should help Resident 21 with breakfast. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 9 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 CNA 2 stated she was supposed to help Resident 21 sit in a chair, and cut the foods for the resident. CNA 2 stated she put some butter on the toast, and she was going to come back to help Resident 21.

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

F685 09/24/2019 §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 medical record review, the facility failed to address a hearing problem for one of 12 final sampled residents (Resident 20). Resident 20 had a hearing loss. The facility failed to assess, develop the plan of care, and implement the interventions for Resident 20 to facilitate better communication. This had the potential to impede Resident 20 from maintaining and/or achieving independent functioning, dignity, and well-being. Findings: On 9/3/19 at 0901 hours, an interview was attempted with Resident 20. However, Resident 20 was having a problem hearing and was without a hearing aid. When Resident 20 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 10 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 was asked if she had a hearing aid, Resident 20 could not hear and could not answer. Resident 20 was observed looking for her hearing aids, and could not find them. On 9/5/19 at 0812 hours, an interview was conducted with LVN 3. LVN 3 confirmed Resident 20 was hard of hearing, and did not have hearing aids. LVN 3 stated Resident 20 had a hearing device with amplifier to communicate. Resident 20's family member brought it in when they visited her. Review of Resident 20's medical record was initiated on 9/3/19. Resident 20 was readmitted to the facility on 7/31/11, and readmitted on 8/3/19. Review of Resident 20's Nursing Admission Data Collection dated 8/3/19, Section B Communication/Hearing/Vision, showed Resident 20's ability to hear was adequate. Review of Resident 20's MDS dated 8/10/19, under Section B (Hearing, Speech and Vision), showed Resident 20's ability to hear was adequate (no difficulty in normal conversation, social interaction, listening to TV). Review of Resident 20's care plan failed to show a care plan problem to address Resident 20' s difficulty hearing, and the use of a hearing device with amplifier. The care plan failed to address a communication deficit related to hearing impaired, and the interventions to assist with the use of hearing appliance/hearing aids as needed. On 9/5/19 at 1350 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 11 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/24/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development of the pressure ulcers to two of 12 final sampled residents (Residents 21 and 4). Residents 21 and 4 were admitted to the facility without pressure ulcers but developed pressure ulcers after admission to the facility. * Resident 21 developed a right heel Stage 3 pressure ulcer discovered on 9/4/19. The facility failed to ensure Resident 21's right heel was offloaded (floated off the mattress) to prevent further deterioration of the Stage 3 pressure ulcer on the right heel. This resulted in Resident 21's right heel developing a black blister with non-blanchable (deep tissue injury) discovered on 9/6/19, next to the current wound. The facility failed to assess the new pressure ulcer, notify the physician to obtain a wound treatment order, notify the family, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 12 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 implement the necessary interventions to prevent further skin breakdown. * Resident 4 developed an unstageable pressure ulcer while at the facility. The facility failed to carry out the repeated orders from the Wound Specialist for a change in the treatment of resident 4's wound. The facility failed to carry out a physician's order to not let Resident 4 sit in the wheelchair for more than an hour each time. In addition, the wound assessments by the licensed nurses did not match the assessments completed by the Wound Specialist. Findings: The National Pressure Ulcer Advisory Panel released definitions of pressure ulcers on April 13, 2016. They are as follows: - Stage 2: partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. - Stage 3: full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. - Deep Tissue Injury (DTI): intact or non-intact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. Medical record review for Resident 21 was initiated on 9/3/19. Resident 21 was admitted to the facility on 3/19/13, and readmitted on 8/10/19, without a pressure ulcer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 13 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of the MDS dated 8/17/19, showed Resident 21 was cognitively intact. Review of the Braden Scale for Predicting Pressure Sore Risk dated 8/31/19, showed Resident 21 was a mild risk for developing a pressure ulcer. Review of an untitled wound assessment form dated 9/4/19, showed an initial exam of Resident 21's right heel pressure ulcer Stage 3 with 100% slough, measuring 2.1 cm (length) x 1.1 cm (width) x 0.3 cm (depth). The recommendations included to offload the pressure, reposition the resident every two hours, provide the low air loss mattress, and reposition the resident to the lateral position (lying on the side) in bed. Review of the SBAR Communication Form and Progress Note dated 9/4/19 at 1609 hours, showed Resident 21 had a new full thickness tissue loss to the right heel. Review of the Progress Notes showed an IDT entry dated 9/5/19 at 1918 hours, showing Resident 21 had a new right heel pressure ulcer, Stage 3. The IDT documentation showed to continue the physician's orders for a low air loss mattress, Roho cushion, continue to turn and reposition the resident every two hours for pressure ulcer management. Review of the care plan showed a care plan problem dated 9/4/19, addressing Resident 21's impaired skin integrity related to the right heel full thickness tissue loss (Stage 3 pressure ulcer). The Interventions/Tasks included to provide the treatment as per the physician's order. However, the plan of care failed to show the recommendations from the wound care physician to offload the pressure by elevating FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 14 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 heels and repositioning the resident to the lateral position in bed. On 9/5/19 at 0805 and 1030 hours, Resident 21 was observed lying on her back without the right heel being offloaded. On 9/6/19 at 0830 and 1412 hours, and on 9/9/19 at 1412 hours, Resident 21 was observed lying on her back with right heel placed on the mattress. On 9/6/19 at 1420 hours, a wound treatment observation was conducted with LVN 2 and CNA 1. Resident 21 was observed lying on her back with the right heel resting on the mattress. LVN 2 provided the treatment to Resident 21's right heel pressure ulcer. The wound on the right heel was measured 2 cm x 2 cm x UTD (unable to determine [depth]) with 50% eschar, 50% granular tissue (new tissue). Next to Resident 21's right heel wound a black blister was observed measuring 2 cm (length) x 2 cm (width) x UTD. LVN 2 stated now Resident 21's right heel had a blister with a dark area (DTI) next to the previous wound, and this blister was a new wound. After the wound treatment, LVN 2 and CNA 1 were observed placing Resident 21's right heel directly on the mattress. On 9/9/19 at 0709 hours, a concurrent observation and interview was conducted with RN 3. Resident 21 was observed lying on her back with the right heel resting directly on the mattress. RN 3 stated Resident 21 was supposed to be repositioned every two hours and the right heel was supposed to be elevated on pillows to prevent further skin breakdown. On 9/9/19 at 0853 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 15 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 wound care physician discovered Resident 21's right heel pressure ulcer on 9/4/19, and the DTI was discovered on 9/6/19, during the wound treatment. The ADON stated when the nurse found a new pressure ulcer, she was supposed to assess the wound, inform the physician and family, fill out the Change of Condition and SBAR Communication Forms, and update the plan of care. The ADON called LVN 2 on the phone regarding Resident 21's pressure ulcer on the right heel discovered on 9/6/19. LVN 2 confirmed Resident 21's pressure ulcer on the right heel was not assessed, not documented in the Change of Condition and SBAR Communication Forms, and was not updated on the plan of care. LVN 2 stated she endorsed the finding to the evening shift licensed nurse, LVN 3. On 9/9/19 at 1400 hours, an observation of Resident 21's right heel pressure ulcer was conducted with the ADON, RN 2, and LVN 3. The ADON removed the soiled dressing on the right heel. The Stage 3 pressure ulcer and the black blister were adjacent and became one large pressure ulcer, measuring 4 cm (length) x 3.1 (width) x 0.2 cm depth. The right heel pressure ulcer was observed with separated skin, 30% black eschar, and 70% granular tissue. LVN 3 stated the wound had changed and was getting larger. 2. Medical record review for Resident 4 was initiated on 9/3/19. Resident 4 was admitted to the facility on 8/13/14. Review of Resident 4's quarterly MDS dated 7/9/19, showed Resident 4 required extensive assistance from two persons for all ADL care. a. Review of the BD Change of Condition dated 6/6/19, showed Resident 4 developed an unstageable pressure ulcer to her mid back. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 16 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of the Medication Review report showed an order dated 8/11/19, for Santyl ointment (debriding ointment) 250 unit/gm, apply to mid back topically every day shift for an unstageable pressure ulcer, offload the pressure, reposition the resident frequently everyday, and have the resident sit in the wheelchair no more than one hour at a time. Review of the Wound Specialist's progress notes dated 8/24/19, showed Resident 4 had a Stage 3 pressure ulcer at the mid back, measuring 1 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The wound bed had 100% granulation. An order was written to cleanse or irrigate the wound with normal saline or water and apply Manuka honey and cover with a foam dressing. Review of the medical record failed to show documentation this order was carried out. Review of the Wound Specialist's progress note dated 8/28/19, showed Resident 4 had a Stage 3 pressure ulcer at the mid back, measuring 0.8 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The wound bed was 60% granulation and 40% epithelialization. Another order was written to cleanse or irrigate the wound with normal saline or water and apply Manuka honey and cover with foam dressing. Review of the medical record failed to show documentation this repeated order was carried out. On 9/3/19 at 0751 hours, Resident 4 was observed in the dining room, sitting in her wheelchair with her back hunched over. The bony area of her back was observed resting on the back of the wheelchair. On 9/3/19 at 1028, 1104, 1217, and 1227 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 17 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 hours, Resident 4 was observed in her wheelchair in activities and dining room for lunch. On 9/5/19 at 0820 to 0935 hours, Resident 4 was observed sitting on her wheelchair in the dining room being fed breakfast. Resident 4 was then wheeled from the dining room to the activities room. On 9/5/19 at 1053 hours, an observation and concurrent interview was conducted with the Activities Director. Resident 4 was observed sitting in her wheelchair in the activities room. The Activities Director verified Resident 4 had been in activities for at least an hour now. On 9/5/19 at 1109 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 4 was brought to the dining room for breakfast at 0745 hours and was wheeled to the activities room after breakfast. On 9/5/19 at 1407 hours, a wound care observation of Resident 4 was conducted with LVN 1. LVN 1 was observed providing wound care to the bony area of Resident 4's mid back. LVN 1 was observed applying Santyl ointment to the wound and covering the wound with a foam dressing. On 9/6/19 at 1056 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated the current treatment order for Resident 4's pressure ulcer was the Santyl ointment and was never changed to Manuka honey which was ordered by the Wound Specialist on 8/24/19. LVN 1 stated the Wound Specialist's order or recommendation was not communicated to Resident 4's physician; therefore, the treatment order was not changed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 18 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 9/6/19 at 1415 hours, a follow-up wound care observation of Resident 4 was conducted with LVN 1. LVN 1 measured Resident 4's wound at mid back as 0.5 cm (length) x 1 cm (width). The wound bed was observed to be 80% slough and 20% granulation. b. Review of the BD SBAR Communication Form and Progress Note dated 6/6/19, showed Resident 4's physician was notified of the development of an unstageable pressure ulcer to her "back bony prominence," measuring 4 cm (length) x 2 cm (width). There was no other description of the wound. Review of the BD Weekly Wound Data Collection Flow Sheet dated 6/8/19, showed Resident 4 had a DTI at mid back, measuring 4 cm (length) x 2 cm (width). The area to document a description of the wound base was blank. The wound edges were purple and intact. There was no odor or drainage. Under the section for Summary, the Flow Sheet showed Resident 4 had a mid back unstageable pressure ulcer. Resident 4's wound at the mid back was described as both unstageable and DTI in one assessment. Review of the Wound Specialist's progress note dated 8/18/19, showed Resident 4's wound at the mid back was now a Stage 3 pressure ulcer, measuring 1.1 cm (length) x 0.7 cm (width) x 0.1 cm (depth). The wound bed was 20% slough and 80% granulation. However, review of the BD Weekly Wound Data Collection Flow Sheet dated 8/17/19, signed by the DCS showed Resident 4's wound at the mid back was unstageable/DTI, measuring 2.8 cm (length) x 1.6 cm (width). The areas to describe the wound base were blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 19 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of the Wound Specialist's progress note dated 8/24/19, showed Resident 4's Stage 3 pressure ulcer at the mid back measured 1 cm (length) x 0.4 cm (width) x 0.1 cm (depth). The wound bed was 100% granulation. However review of the BD Weekly Wound Data Collection Flow Sheet dated 8/24/19, signed by the DCS, showed Resident 4's wound at the mid back was unstageable/DTI measuring 2 cm (length) x 1.4 cm (width). The areas to describe the wound base were blank. On 9/6/19 at 1503 hours, an interview and concurrent medical record review was conducted with the DCS and ADCS. The ADCS stated the Wound Specialist assessed Resident 4's wound independently. No one from the nursing staff followed the Wound Specialist. The ADCS stated the nursing staff assessed Resident 4's wounds separately. They did not do it at the same time. The DCS verified the discrepancies in the wound assessments and stated all the wound assessments were done by the ADCS, and the DCS signed the assessments. When asked if she had seen or assess the wounds herself before signing, the DCS had no answer.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/24/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 20 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the fall interventions were in place for one of 12 final sampled residents (Residents 10). Resident 10 did not have floor mats in place as per the plan of care. This failure had the potential of not protecting the resident from injury related to any future falls. Findings: On 9/3/19 at 0924 hours, an observation and concurrent interview was conducted with Resident 10. Resident 10 was observed in bed with the bed in the low position. A yellow star was noted by his name on the outside of his room. Resident 10 stated he had two recent falls at the facility. The resident stated, after the second fall, he was sent to the hospital for an injury to his abdomen. Resident 10 was asked if anything had been done by the facility to prevent him from falling again. Resident 10 stated the only thing he knew was previously, he had floor mats in his room. No floor mats were observed on either side of Resident 10's bed. Medical record review for Resident 10 was initiated on 9/3/19. Resident 10 was admitted to the facility on 6/24/19, and readmitted on 8/16/19. Review of the History and Physical examination from the acute care hospital dated 8/14/19, showed Resident 10 had a history right sided weakness of the lower extremity. Review of Resident 10's Progress Notes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 21 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 showed a "late entry" dated 8/7/19 at 1200 hours, documenting Resident 10 had an unwitnessed fall. Another "late entry" dated 8/14/19 at 1300 hours showed Resident 19 had an unwitnessed fall with injury and was transferred to the hospital on 8/14/19. Review of Resident 10's plan of care showed a care plan problem created on 6/24/19, and initiated on 8/16/19, addressing Resident 10's recent unwitnessed falls on 8/7/19, with no injury and on 8/14/19, with injury. The Interventions/Tasks included floor mats at the bedside. On eight occasions, Resident 10 was observed in bed without floor mats at his bedside. * 9/3/19 at 0924 hours; * 9/3/19 at 1522 hours; * 9/4/19 at 1531 hours; * 9/5/19 at 1552 hours; * 9/6/19 at 0846 hours; * 9/6/19 at 0900 hours; * 9/6/19 at 1351 hours; * 9/6/19 at 1421 hours. On 9/5/19 at 1558 hours, an observation and concurrent interview was conducted with LVN 1 and LVN 3. LVNs 1 and 3 both verified Resident 10 had no floor mats in place on either side of the bed. LVN 3 stated Resident 10 needed bilateral floor mats to prevent falls. LVN 3 stated Resident 10 was moved from a previous room and the floor mats had not gone with him. LVN 3 stated she would have the floor mats provided for Resident 10. On 9/6/19 at 0827 at hours, an interview was conducted with CNA 2. CNA 2 stated Resident 10 was on the falling star program. CNA 2 stated Resident 10 was at a high risk for falls. When asked if Resident 10 had sustained any falls, CNA 2 stated she was not aware of any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 22 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 falls sustained by Resident 10. CNA 2 stated she would only know about a fall if the resident had fallen on her shift. On 9/6/19 at 0900 hours, an observation and concurrent interview was conducted with the DCS. The DCS walked into Resident 10's room and verified no floor mats were on Resident 10' s floor. The DCS stated Resident 10 had fallen on both 8/7/19 and on 8/14/19. The DCS stated Resident 10's care plan for falling had been created by her. The DCS verified the care plan included floor mats at the bed side as interventions to prevent falling. The DCS stated to prevent future falls, the floor mats should be in the resident's room. On 9/6/19 at 0927 hours an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 10. CNA 3 stated she was aware Resident 10 was on the falling star program. CNA 3 stated no one at the facility had given her formal report about either of Resident 10's two falls. CNA 3 stated she was unaware he had fallen a second time. CNA 3 stated she was unaware Resident 10 had floor mats as part of his interventions for falls. On 9/6/19 at 1433 hours an observation, and medical record review with was conducted with the ADCS. The ADCS walked into Resident 10's room and verified no floor mats were on Resident 10's floor. The ADSC was shown the current care plan for Resident 10 and verified the care plan did show Resident 10 was to have bilateral floor mats.

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

F690 09/24/2019 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 23 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 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. §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 medical record review, the facility failed to provide appropriate services to care for a suprapubic urinary catheter for one nonsampled resident (Resident 334). This posed the risk for urinary tract infections related to the use of suprapubic urinary catheters. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 24 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 9/3/19 at 1530 hours, an observation and concurrent interview was conducted with Resident 334. Resident 334 was observed picking on the rubber band securing the supra pubic catheter and the urinary drainage bag (leg bag) tight to her right upper leg. When asked what Resident 334 was doing, Resident 334 stated she tried to empty her urinary bag, and stated she did it herself at home. The urinary drainage bag was observe full of urine. Review of Resident 334's medical record was initiated on 9/3/19. Resident 334 was readmitted to the facility on 9/2/19, with a suprapubic catheter. Review of the History & Physical examination from the acute care hospital dated 8/29/19, showed Resident 334 had a history of recurrent urinary tract infections. On 9/4/19 at 0800 hours, an observation and concurrent interview was conducted with RN 2. Resident 334 was observed lying in bed, the suprapubic catheter was tight to her right upper leg with the urinary drainage bag full of urine. RN 2 stated the urinary leg bag was supposed to be changed to the urinary collection bag, and to hang at a level lower than the bladder to prevent the urine from flowing back into the bladder. On 9/4/19 at 0826 hours, an interview and concurrent medical record review was conducted with the ADON. When asked about changing the urinary leg bag to the urinary collection bag to prevent the urine from flowing back into the bladder. The ADON stated the nurse was supposed to change the urinary leg bag to the urinary collection bag at night. The ADON stated the physical therapist preferred Resident 334 have a urinary leg bag so it is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 25 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 easier for the resident to walk. The ADON was asked if the nurse changed the urinary leg bag to the urinary collection bag last night. The ADON stated no, they did not change the bag last night.

F694 SS=F Parenteral/IV Fluids CFR(s): 483.25(h)

F694 09/24/2019 § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of five current residents (Residents 9, 16, 27, 281, and 332) and four closed record nonsampled residents (Residents 282, 283, 284, and 285) with central vascular access devices received appropriate care and services regarding vascular access devices. The facility failed to follow their P&P to perform the sterile dressing changes upon admission, assess the catheter site for complications, and obtain the measurements of the external length of the catheter and arm circumference upon admission and weekly thereafter. These failures posed the risk for the residents to develop complications such as catheter-related infections, catheter-associated venous thrombosis (blood clot in the vein), catheter migration, and dislodgement. Findings: Review of the facility's P&P titled Central Vascular Access Device (CVAD) Dressing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 26 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Change revised 5/1/15, showed CVADs include PICCs. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Sterile dressing change using transparent dressings is performed upon admission, at least weekly, and if the integrity of the dressing has been compromised (wet, loose, or soiled). Assessment of the vascular access site is performed upon admission and during dressing changes, at least every two hours during continuous therapy, before and after administration of intermittent infusions, or at least once every shift when not in use. Length of the external catheter is obtained upon admission, during dressing changes, upon suspicion in change of length, and if signs and symptoms of complications are present. For PICCs, upper arm circumference is obtained upon admission if no insertion measurement is available, then weekly. 1. On 9/3/19 at 0938 hours, an observation and subsequent interview of Resident 16 was conducted. Resident 16 was observed with a PICC line in the left upper arm. Resident 16 stated she had a PICC line and was receiving the IV therapy for a bone infection. Medical record review for Resident 16 was initiated on 9/4/19. Resident 16 was originally admitted to the facility on 3/14/18, and readmitted on 8/26/19. Review of Resident 16's MDS dated 9/2/19, showed the resident was cognitively intact. Review of the BD Nursing Admission Data Collection dated 8/26/19, showed Resident 16 was admitted with a PICC line at the left upper arm. There was no documentation the external catheter length or the arm circumference were measured. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 27 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of Resident 16's physician's orders dated 9/3/19 showed the PICC line dressing change for Resident 16 was to be changed every Tuesday on the day shift with the first dressing change to be completed on 9/3/19. On 9/5/19 at 0846 hours, an observation of Resident 16 was conducted with the DCS. The DCS stated she was providing the IV therapy to Resident 16. Resident 16 was observed with a PICC line at the left upper arm. The dressing was dated 8/27/19. The DSC stated the dressing changes for PICC lines were to be completed every seven days. The DSC verified Resident 16's PICC line dressing change was past due. The DSC stated she would change it today (9/5/19). Review of the Treatment Administration Record dated 9/1/19, showed a PICC line dressing change had been signed as completed on 9/3/19 by RN 2. On 9/6/19 at 0929 hours, an additional observation of the IV therapy was conducted with the DCS. Resident 16 was observed again with a PICC line dressing dated 8/27/19. The DCS stated the PICC line dressing change was not performed on 9/5/19, because she was too busy. Resident 16 also stated a dressing change was originally performed on 8/27/19, and no new dressing change had occurred. On 9/6/19 at 1502 hours, an interview was conducted with the DCS. The DCS reviewed the Treatment Administration Record and verified the resident did not have a dressing change as signed by RN 2. The DCS verified the dressing change was performed on 9/6/19, by the DCS, not on 9/3/19, as signed in the Treatment Administration Record by RN 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 28 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 9/6/19 at 1537 hours, an interview and concurrent medical record review was conducted with the DCS. The DCS stated she was the only RN in the facility today for the 0700 to 1500 hours shift. The DCS stated there were currently three residents with PICC lines in the facility. When asked if the PICC line dressing was changed on admission per their P&P, the DCS stated no, they do not change the dressing until seven days after because the physicians did not want the PICC line dressings changed on admission. However, the DCS failed to provide documentation the physician was informed and declined to give an order for PICC line dressing changes on admission. The DCS stated they did not obtain measurements of the external length of the catheter and the arm circumference upon admission and weekly. Further medical record review showed there were four current residents with PICC lines in the facility. 2. On 9/6/19 at 1404 hours, an observation of Resident 281 and concurrent interview was conducted with the DCS. Resident 281 was observed with a PICC line in the right upper arm. The dressing was dated 8/31/19. The DCS stated the dressing was from the acute care hospital. Medical record review for Resident 281 was initiated on 9/6/19. Resident 281 was admitted to the facility on 9/3/19. Review of the BD Nursing Admission Data Collection dated 9/3/19, showed Resident 281 was admitted with a PICC line in the right upper arm. The external catheter length was 1 cm. There was no documentation the arm circumference was measured, nor was the dressing changed upon admission. Cross reference to F880, example #2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 29 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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. On 9/6/19 at 1407 hours, an observation of Resident 9 and concurrent interview was conducted with the DCS. Resident 9 was observed with a PICC line at the right upper arm. The dressing was dated 9/3/19. The DCS stated the dressing was from the acute care hospital. Medical record review for Resident 9 was initiated on 9/6/19. Resident 9 was readmitted to the facility on 9/5/19. Review of the BD Nursing Admission Data Collection dated 9/5/19, showed Resident 9 was admitted to the facility with a PICC line in the right upper arm. The external catheter length was measured at 1 cm. There was no documentation the dressing was changed, nor was the arm circumference measured on admission. 4. Medical record review for Resident 332 was initiated on 9/3/19. Resident 332 was admitted to the facility on 8/26/19. Review of the BD Nursing Admission Data Collection dated 8/26/19, showed Resident 332 was admitted to the facility with a PICC line in the left upper arm. There was no documentation the dressing was changed, nor was the external length of the catheter and the arm circumference measured upon admission. 5. Medical record review for Resident 27 was initiated on 9/3/19. Resident 27 was admitted to the facility on 8/9/19. Review of the BD Nursing Admission Data Collection dated 8/9/19, showed Resident 27 was admitted to the facility with a PICC line in the right upper arm. There was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 30 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 documentation the PICC access site was assessed, nor was the external catheter length and arm circumference measured on admission. There was no documentation the PICC line dressing was changed on admission. 6. Closed medical record review for Resident 282 was initiated on 9/9/19. Resident 282 was admitted to the facility on 7/5/19, and was discharged on 8/6/19. Review of the BD Nursing Admission Data Collection dated 7/5/19, showed Resident 282 was admitted to the facility with a PICC line in the left upper arm. There was no documentation the PICC line dressing was changed, nor was the external length of the catheter and the arm circumference measured on admission. Review of the Medication Review Report showed an order dated 7/6/19, to change the PICC line dressing weekly, every Friday. Review of the Treatment Administration Record for July 2019 showed the PICC line dressing was changed on 7/12 and 7/28/19. There was no documentation the PICC line dressing was changed on 7/19/19, as ordered. Review of the medical record failed to show documentation the PICC line was assessed, nor was the external length of the catheter and the arm circumference measured while Resident 282 was in the facility. 7. Closed medical record review for Resident 284 was initiated on 9/9/19. Resident 284 was admitted to the facility on 8/9/19, and was discharged on 8/16/19. Review of the BD Nursing Admission Data FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 31 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Collection dated 8/9/19, showed Resident 284 was admitted to the facility with a PICC line in the right upper arm. There was no documentation the PICC line dressing was changed, nor was the external length of the catheter and the arm circumference measured on admission. 8. Closed medical record review for Resident 283 was initiated on 9/9/19. Resident 283 was admitted to the facility on 8/7/19, and was transferred to the acute care hospital on 8/9/19. Review of the BD Nursing Admission Data Collection dated 8/7/19, showed Resident 283 was admitted to the facility with a PICC line in the right upper arm. There was no documentation the PICC line access site was assessed, nor was the external length of the catheter and the arm circumference measured, nor was the dressing changed on admission. 9. Closed medical record review for Resident 285 was initiated on 9/9/19. Resident 285 was admitted to the facility on 3/9/19, and was discharged on 4/16/19. Review of the BD Nursing Admission Data Collection dated 3/9/19, showed Resident 285 was admitted to the facility with a PICC line in the left upper arm. There was no documentation the PICC line dressing was changed on admission; nor was the external length of the catheter and the arm circumference measured on admission and weekly. On 9/9/19 at 1502 hours, a telephone interview was conducted with the Medical Director. The Medical Director stated he expected the facility to follow their P&P on management of the PICC lines or any central vascular access devices. The Medical Director stated this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 32 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 included making sure the catheter was in the correct placement. On 9/10/19 at 0939 hours, an interview and concurrent medical record review was conducted with the DCS. The DCS verified the above findings and stated the PICC line access sites were not assessed upon admission if there was no RN working on that shift. The DCS stated they implemented their P&P on PICC line management, specifically regarding dressing change, assessments, obtaining measurements of the external length of the catheter and arm circumference, only this week. Cross reference to F726.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 09/24/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: 3. Medical record review for Resident 333 was initiated on 9/3/19. Resident 3 was admitted to the facility on 8/25/19. Review of Resident 333's Medication Review Report dated 9/4/19, showed an order dated 8/25/19, to administer oxygen at 3 liters per minute via nasal cannula continuously for shortness of breath every shift related to "acute on chronic" congestive heart failure, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 33 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 pulmonary embolism (arteries in the lungs become blocked by a blood clot). On 9/3/19 at 1520 hours, Resident 333 was observed sitting in a wheelchair in her room wearing a nasal cannula connected to an oxygen tank with the gauge set at 2 liters per minute. The oxygen tank gauge was observed in the red zone (refill area) and showed zero (empty). LVN 4 confirmed the finding, and checked resident 333's oxygen saturation; however, Resident 333's oxygen saturation could not be obtained. Resident 333 stated she felt chest tightness for a few hours. On 9/4/19 at 1430 hours, an observation was conducted with Resident 333 at the bedside. Resident 333 was observed receiving oxygen at 2 liters per minute via nasal cannula connected to an oxygen concentrator. On 9/4/19 at 1630 hours, an observation and concurrent interview was conducted with the ADON. Resident 333 was observed sitting in a wheelchair in the activities room receiving oxygen at 2 liters per minute via nasal cannula connected to an oxygen tank. The ADON verified the oxygen tank and the oxygen concentrator in Resident 333' room were set at 2 liters per minute. Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure two of 12 final sampled residents (Residents 3 and 333) and one nonsampled resident (Resident 27) received the necessary care and treatment for oxygen therapy. * The facility failed to ensure Residents 3 and 27 received the necessary care for breathing treatments via CPAP and BiPAP machines. * The facility failed to provide oxygen treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 34 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 as ordered by the physician to Residents 333. These posed the risk of the residents not receiving the appropriate breathing treatments and negatively impact the residents' medical conditions. Findings: Review of the facility's P&P titled CPAP/BiPAP Policy revised 9/2017 showed storage and cleaning included the following: - the mask was to be washed daily in mild, fragrance-free soap and warm water, then rinse well in warm water and air dry; - wash humidification chamber, using mild soap and warm water daily, then air dry; - wash tubing using vinegar water solution, mild soap and warm water twice a week and as needed, hang dry for best results; - wash headgear and chin supports once a week in warm water with mild detergent, rinse in warm water and air dry; - clean filter weekly with a mild soap solution in warm water, rinse and air dry; replace filter every two months or as needed. 1. Medical record review for Resident 3 was initiated on 9/3/19. Resident 3 was admitted to the facility on 6/3/19. On 9/4/19 at 1043 hours, Resident 3 was observed lying in bed receiving oxygen at three liters per minute through a nasal cannula (a tube with two prongs which fit in the nostrils to deliver oxygen). A CPAP machine was observed at Resident 3's bedside with the mask and tubings inside a bag. Review of the Medication Review Report showed a physician's order dated 7/5/19, for CPAP at bedtime for sleep apnea. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 35 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of the Medication Administration Records for August and September 2019 showed Resident 3's CPAP was scheduled to be administered daily at 2100 hours and to be turned off the following day at 0900 hours. Review of the plan of care showed a care plan problem dated 6/4/19, to address Resident 3's impaired airway clearance. The interventions/tasks included to assist Resident 3 in applying the CPAP machine. The interventions did not include instructions on how to clean and maintain the CPAP machine. On 9/4/19 at 1553 hours, an interview was conducted with LVN 4. LVN 4 stated she administered Resident 3's CPAP at bedtime multiple times. When asked how they cleaned the machine, mask, tubings, and filter, LVN 4 stated she did not know because she had not cleaned them before. On 9/4/19 at 1622 hours, an interview and concurrent medical record review was conducted with the ADCS. The ADCS stated she was also the facility's DSD and the facility's Infection Control Nurse. The ADCS was asked if there was any documentation to show when Resident 3's CPAP machine and tubing were cleaned and when the filter was changed. The ADCS was unable to find any documentation to show the last time Resident 3's CPAP machine and tubing were last cleaned or a cleaning schedule. The ADCS stated the resident's plan of care should include the care and cleaning of the CPAP machine. 2. Medical record review for Resident 27 was initiated on 9/3/19. Resident 27 was admitted to the facility on 8/9/19. On 9/4/19 at 0840 hours, Resident 27 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 36 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 observed lying in bed. A BiPAP machine was observed at Resident 27's bedside. Review of the Medication Review Report showed a physician's order dated 8/10/19, for BiPAP at bedtime. Review of Resident 27's plan of care failed to show documentation on how to clean and manage the BiPAP machine. On 9/4/19 at 1555 hours, an interview was conducted with LVN 4. LVN 4 stated she administered Resident 27's BiPAP at bedtime as needed. When asked how they clean the machine, mask, tubings, and filter, LVN 4 stated she did not know because she had not cleaned them before. On 9/4/19 at 1640 hours, an interview and concurrent medical record review was conducted with the ADCS. The ADCS verified the above findings. The ADCS was unable to find any documentation to show the last time Resident 27's BiPAP machine and tubing were last cleaned or a cleaning schedule. The ADCS stated the resident's plan of care should include the care and cleaning of the BiPAP machine.

F726 SS=F Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 09/24/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 37 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of three Registered Nurses (the DCS, RN 1 and RN 2) who worked the 0700 to 1500 hours shift had appropriate competency and skill sets to provide nursing and related services to assure resident safety. The facility failed to ensure the three Registered Nurses were competent in the management of central vascular access devices. This failure posed the risk of catheter migration or dislodgement not being detected. Findings: On 9/6/19 at 1623 hours, a concern regarding the facility not following their P&P on PICC line care was brought to the attention of the Executive Director and DCS. The DCS verified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 38 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 residents who were admitted with central vascular access devices, including the PICC line were not assessed, the dressing changes were not done, the external length of the catheter and arm circumference was not measured on admission. The DCS stated there were three residents (Residents 9, 16, and 281) who currently had PICC lines. Review of the facility's P&P titled Measuring External Catheter Length with Central Vascular Access Devices dated 11/2018 showed when measuring external catheter length, measure from the hub (point where the catheter width increases) of the catheter to the insertion site of the catheter. Measuring the external catheter length and comparing to the external catheter length at insertion will confirm the catheter's tip has remained in the SVC (superior vena cava, large vein that carries blood into the heart). If the baseline was documented at 1 cm upon insertion, and the measurement just taken was 4 cm, do not use the catheter until an x-ray confirms the tip placement is located in the SVC. According to Taylor's Clinical Nursing Skills, third edition, if a patient has a PICC in place, measure the length of the catheter that extends from the insertion site. Measurement of the extending catheter can be compared with the documented length at the time of insertion to assess if the catheter has migrated inward or moved outward. On 9/9/19 at 0704 hours, the DCS provided copies of her assessments of the PICC line access sites for Residents 9, 16, 281, and 332). The DCS stated Resident 332 also had a PICC line. Review of the Body Assessment forms provided by the DCS showed the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 39 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 measurements of the external length of the catheters: - For Resident 9: 13.5 cm (however, the admission assessment dated 9/5/19, showed the external catheter length was 1 cm); - For Resident 16: 19 cm (no baseline measurement available in the medical record); - For Resident 281: 13 cm (however, the admission assessment dated 9/3/19, showed the external catheter length was 1 cm); and - For Resident 332: 14.5 cm (no baseline measurement available in the medical record). On 9/9/19 at 0803 and 0839 hours, an interview and concurrent medical record review was conducted with the DCS. The DCS stated she measured the external catheter length by measuring from the insertion site all the way to tip of the infusion cap. The DCS stated she measured "...the whole length" of the catheter. The DCS was asked if she had noted the discrepancies of her measurements of the external length of the catheter for Residents 9 and 281 with the previous measurements obtained on admission. The DCS had no answer. The DCS reviewed the admission assessments for Residents 9 and 281, and stated she was not aware of this. The DCS stated it was her first time to obtain measurements of the external length of a PICC, so she did not realize the discrepancy. The DCS stated she did not know why her measurements were longer than the previous measurements, but she was sure she did her measurements correctly. When asked if she or any RN in the facility had received any inservice on management of central vascular access devices, the DCS stated no. a. On 9/9/19 at 0811 hours, observation of the measurement of the external catheter length of Resident 281's PICC was conducted with the DCS. Resident 281 was observed with a PICC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 40 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 line access site to the right upper arm. The access site was covered with a transparent dressing. The insertion site was not visible because it was covered with a biopatch (a polyurethane foam disc containing chlorhexidine, used to prevent infection). The DCS was observed to start measuring the external catheter length without removing the transparent dressing. The DCS measured the entire length of the catheter up to the tip of the catheter cap. The DCS stated she measured the external length of the catheter at 13 cm. When asked to measure from the insertion site to the hub, the DCS obtained a measurement of 1.5 cm. b. On 9/9/19 at 0827 hours, observation of the measurement of the external catheter length of Resident 9's PICC was conducted with RN 2. Resident 9 was observed with a PICC line to the right upper arm. RN 2 measured the external length of the catheter from the insertion site up to the infusion port. RN 2 stated she measured the external length of the catheter at 9.5 cm. When asked if she had received an in-service on the management of central vascular access devices, including how to measure the external length of the catheter, RN 2 stated she was trained by RN 1. c. On 9/9/19 at 0942 hours, observation of the measurement of the external catheter length of Resident 332's PICC was conducted with RN 1. RN 1 stated she was the facility's IV nurse today for the 0700 to 1500 hours shift. Resident 332 was observed with a PICC line to the right upper arm. RN 1 measured the external length of the catheter from the insertion site up to the infusion port. RN 1 stated she measured the external length of the catheter at 11 cm. The external length of the catheter from the insertion site to the hub was observed to be approximately 0.5 cm. RN 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 41 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 she used to measure the external length of the catheter from the insertion site up to the tip of the infusion cap; however, RN 2 told her today, she was supposed to measure up to the infusion port only. RN 1 stated, in order to be consistent, she followed how RN 2 was doing it. Review of the employees' in-services and trainings failed to show an in-service or training on central vascular access device management was provided to all the registered nurses in the facility. On 9/9/19 at 1545 hours, an interview was conducted with the Executive Director and the DCS. The Executive Director and the DCS were notified and acknowledged the above findings. The DCS verified there was no inservice or training provided to the RNs, including herself, regarding CVAD management and how to measure the external length of the catheter. The DCS stated it was her first time measuring the external length of the catheter so she thought she did it correctly. Cross reference to F694.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 10/08/2019 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 42 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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, 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 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 interview and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 3 and 25) were free from unnecessary psychotropic medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 43 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 * Residents 3 and 25 were receiving Remeron (antidepressant medication) for depression manifested by poor appetite. The facility failed to accurately monitor the number of episodes in which Residents 3 and 25 had poor meal intake. This posed the risk of Residents 3' s and 25's physicians not having the necessary information to determine the effectiveness of the Remeron. Findings: 1. Medical record review for Resident 25 was initiated on 9/3/19. Resident 25 was admitted to the facility on 7/22/19. Review of the Medication Review Report showed a physician's order dated 8/2/19, for Remeron 15 mg, give one tablet by mouth at bedtime for depression manifested by poor oral intake. There was no parameter as to what percentage of meal intake would be considered poor meal intake. Review of the Medication Administration Record and CNAs documentation of meal intake for August and September 2019 showed multiple inconsistencies in the monitoring of Resident 25's meal intake. For example, on 9/1/19, the CNA's documentation showed Resident 25 refused dinner; however, the licensed nurses documented Resident 25 ate 80% of dinner. On 9/3/19, the CNA documented zero (0-25% of the meal was eaten) for breakfast and coded one (26 to 50% of the meal was eaten) for lunch. However, the licensed nurses documented 50% for breakfast and 60% for lunch. Further review of the Medication Administration Record showed monitoring of poor oral intake by tally hashmarks every shift. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 44 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 documentation showed Resident 25 had zero episodes of poor meal intake for the month of August 2019. However, the CNAs' documentation of meal intake for August 2019 showed Resident 25 was coded zero and one for multiple meals. On 9/4/19 at 1540 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified the above findings and stated a meal intake of 50% or less was considered poor meal intake. RN 3 verified the licensed nurses' documentation of Resident 25's meal intake did not match the CNAs' documentation. On 9/4/19 at 1553 hours, an interview was conducted with LVN 4. LVN 4 stated a meal intake of less than 50% was considered poor meal intake. LVN 4 stated she will code zero in the tally hashmark if there was no episode of meal intake less than 50%. 2. Medical record review for Resident 3 was initiated on 9/3/19. Resident 3 was admitted to the facility on 6/3/19. Review of the Medication Review Report showed a physician's order dated 6/4/19, for Remeron 30 mg, give one tablet by mouth at bedtime for depression manifested by poor meal intake. There was no parameter as to what percentage of meal intake would be considered as poor meal intake. Review of the Medication Administration Record for August and September 2019 showed monitoring of poor meal intake by tally hashmarks every shift. There was no episode of poor meal intake documented for August and September 2019. Review of the CNAs' documentation of meal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 45 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 intake for August and September 2019 showed Resident 3 had multiple episodes of meal intake coded as zero (0-25% of the meal was eaten) and one (26 to 50% of the meal was eaten). On 9/4/19 at 1534 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she considered a meal intake of less than 50% as poor meal intake. LVN 1 verified the licensed nurses' documentation of Resident 3's meal intake did not match the CNAs' documentation.

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

F759 11/22/2019 §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 and interview, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.9%. One of the two nurses (LVN 3) observed administering the medications was found to have errors while administering the medications to one nonsampled resident (Resident 8). This created the risk of complications and ineffective therapeutic effects of the medications. Findings: On 9/5/19, beginning at 0812 hours, a medication administration observation was conducted with LVN 3 for Resident 8. LVN 3 was observed administering seven medications to Resident 8. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 46 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 LVN 3 administered the following medications through the GT: Januvia (antidiabetic) 100 mg, probiotic (bacteria supporting digestive system) one tablet, famotidine (medication to prevent ulcers) 40 mg/5 ml, and vitamin D3 (supplement) 0.5 ml. After administering the medications via GT, a significant amount of residue from the crushed Januvia and probiotic were left in the medication cups. In addition, a significant amount of famotidine and vitamin D3 liquid were left in the medication cups. During an interview with LVN 3 on 9/5/19 at 0840 hours, LVN 3 verified the left over medications were from the Januvia, probiotic, famotidine, and vitamin D3 administered to Resident 8. LVN 3 acknowledged Resident 8 did not receive the full doses of the medications as prescribed. LVN 3 stated she was supposed to use the spoon to mix the medications and rinse the cup of medication with water to administer without left over residue in the medication cup to ensure the resident received the full dose as prescribed.

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 09/24/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 47 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 by: Based on observation, interview, and medical record review, the facility failed to ensure the foods for one of 12 final sampled residents (Resident 26) was consistent with the residents' needs and preferences. This failure had the potential for adverse reactions and negatively impact the residents' well-being. Findings: On 9/3/19 at 1227 hours, Resident 26 was observed eating lunch in her room. Resident 26 showed her menu, which had a diet order of regular, no salt at the table. Resident 26 stated she had requested small portions and written no yogurt on her menu. Resident 26's lunch tray was observed as a regular diet with normal portion sizes of food and yogurt on the tray. Resident 26 stated she was upset the dietary staff had not honored her wishes as written on her menu. Resident 26 stated she had made several requests to both dietary staff and the nursing staff for smaller portions and no yogurt. Resident 26 stated she felt as if the dietary and nursing staff did not listen to her request. Resident 26 stated receiving the extra food and yogurt made her feel frustrated. Medical record review for Resident 26 was initiated on 9/4/19. Resident 26 was originally admitted to the facility on 8/29/13, and readmitted on 8/5/19. Review of Resident 16's MDS dated 9/2/19, showed the resident was cognitively intact. On 9/3/19 at 1235 hours, LVN 3 returned to Resident's 26 room and looked at both the tray and the menu. LVN 3 verified the menu requests made by Resident 26 had not followed by the dietary staff. LVN 3 stated she would call a member of dietary department to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 48 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 speak with Resident 26. On 9/3/19 at 1242 hours, the Certified Dietary Manager arrived to Resident 26's room. The Certified Dietary Manager also looked over Resident 26's menu. The Certified Dietary Manager stated it was her job to verify the resident's requests. The Certified Dietary Manager stated the staff tried to follow the requests, but the menu requests were not implemented into the system due to the holiday weekend. The Certified Dietary Manager verified the above findings.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 09/24/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 49 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 document review, and facility P&P review, the facility failed to follow proper sanitation, food handling, and storage practices. * The facility failed to ensure kitchenware and tableware were presented so only the handles were touched by dietary staff. * The facility failed to ensure the kitchen equipment was clean. * The dietary staff failed to use proper hand hygiene. These failures had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings: Review of the Form CMS-672, Resident Census and Conditions of Residents, completed by the facility and dated 9/3/19, showed 35 of the 38 residents residing in the facility received food prepared in the dietary department. 1. According the USDA Food Code 2017, 4904.11, Kitchenware and tableware, knives, forks, and spoons that are not pre-wrapped shall be presented so only the handles are touched by employees. On 9/3/19 beginning at 0800 hours, an initial tour of the kitchen was conducted with assistance from the Director of Dining Services. During the tour, a clear, plastic bin was observed with multiple utensils sticking out in all different directions without any uniformity to the handles. The Director of Dining Services stated, to prevent cross-contamination, the utensil handles should all be sticking out of the bin in a uniform direction, to confirm serving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 50 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 utensils were touched by the handles and not by the part of the utensil that touches the food. 2. According to the USDA Food Code 2017, 4602.13, Non-Contact Surfaces, nonfoodcontact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During the initial tour, two white paper towels were wiped along the edge of the stove hood. A brown, oily substance was observed on each paper towel. The Director of Dining Services stated cleaning the ledge was to be done weekly when the over filters were cleaned. The Director of Dining Services stated he did not know when the oven hood ledge was last cleaned. The Director of Dining Services verified the brown, oily substance. 3. Review of the facility's P&P Hand Washing dated 2012 and last revised 12/12 showed handwashing was the most important component to prevent the spread of infection. The document showed handwashing was to be done after combing hair. Review of the facility's P&P Washing and Sanitizing dishes dated 2005 and last revised 2018 showed proper hand washing technique or sanitizer must be used between the handling of soiled and clean dishes. On 9/4/19 at 1014 hours, an observation of the dish staff occurred with the Director of Dining Services. Dishwasher 1 was observed taking a dirty dish rack with silverware and placing the rack on the clean side of the dish washer, next to clean pans. The Director of Dining Services stated to prevent cross-contamination, dirty dish racks do not go on the clean side of the dish machine. The Director of Dining Services verified the findings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 51 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 9/4/19 at 1045 hours, an observation and subsequent interview was conducted with Dishwasher 1. Dishwasher 1 was observed as the only dishwasher in the dish area. Dishwasher 1 was observed washing soiled dishes and unloading clean dishes without performing hand hygiene in between. Dishwasher 1 was also observed unloading clean dishes without performing hand hygiene after touching his hair. Dishwasher 1 stated he was the only dishwasher and was both washing and unloading the dishes. He also stated his head itched and he didn't think about it. Dishwasher 1 acknowledged a hand wash sink was available in the area to wash his hands, but he just did not use it. Dishwasher 1 verified the findings.

F814 SS=D Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 10/23/2019 §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in two of two trash dumpsters, one grey trash can and one recycle dumpster. * The garbage and recycle dumpsters were overflowing with garbage, which prevented the lids from fully closing. * Eight white garbage bags were observed on the ground by both trash dumpsters. In addition, multiple cardboard boxes were observed in front of the recycle dumpster. Failure to keep the garbage covered had the potential to harbor pests or rodents, which carried diseases. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 52 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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: On 9/3/19 at 0800 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the Director of Dining Services of the garbage area near the kitchen. An observation of Dumpsters 1 and 2 found both dumpsters' lids were propped open by trash bags full of garbage, preventing the lids from fully closing. Eight white garbage bags were observed on the ground near and in front of both Dumpsters 1 and 2. An additional grey garbage can with overflowing trash was also noted. Multiple stacks of card board boxes were observed on the ground next to the recycle dumpster. The Director of Dining Services verified the above findings. The Director of Dining Services stated the eight bags should not be on the ground because it could cause problems with pests. On 9/3/19 at 0817 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the trash bags and recycling should not to be on the ground. The Director of Maintenance stated the facility did not have enough trash receptacles for all the trash produced over the holiday weekend. The Director of Maintenance stated Regular trash was picked up six days a week, Monday through Saturday and twice on Wednesday. The Director of Maintenance verified nothing extra was done to accommodate the trash for the Monday holiday. The Director of Maintenance verified the findings.

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

F880 09/24/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 53 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 54 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 (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. §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 facility P&P review, the facility failed to maintain infection control practices designed to help prevent the development and transmission of diseases and infection. * LVN 2 was observed not performing hand hygiene during four dressing changes for Resident 381. * The facility failed to ensure sterile technique during the PICC line external catheter measurement and dressing change for Resident 281. These failures posed the risk for transmission of disease-causing microorganisms. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 55 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of the CDC's hand hygiene guidelines for healthcare providers showed healthcare providers should perform hand hygiene immediately before and after touching a resident or the resident's immediate environment. Review of the facility's P&P titled Handwashing/Hand Hygiene, revised date 9/2017, showed hand hygiene was the primary means to prevent the spread of infections. Hand washing or hand hygiene was expected before donning gloves, before handling clean or soiled dressings, after contact with resident skin, after handling used dressings and after removing gloves. 1. On 9/6/19 at 1045 hours, LVN 2 was observed changing Resident 381's four dressings. LVN 2 was observed donning gloves to provide wound care to Resident 381's head, bilateral hands and coccyx. LVN 2 removed gloves and reapplied new gloves without hand hygiene between each removal of the Resident's dressings and between providing wound care to each area of the resident's body. a. LVN 2 was observed cleaning the head and nose of Resident 381. LVN 2 cleaned the wound bed and applied both medication and a band aid to Resident 381's nose. LVN 2 removed her gloves and donned new gloves. No hand hygiene between the removal of the previous dressing and application of the new gloves was observed. b. LVN 2 removed the dressing from Resident 381's left hand. Resident 381's dressing was observed to have a small amount of exudate. LVN 2 removed her gloves and donned new gloves. No hand hygiene between the removal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 56 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 of the soiled dressing and application of new gloves was observed. LVN 2 cleaned the wound bed and applied both medication and a clean dressing to Resident 381's left hand. LVN 2 removed her gloves and reapplied new gloves. No hand hygiene was observed. c. LVN 2 removed the gauze wrap and the previous dressing from Resident 381's right hand. LVN 2 removed her gloves and donned new gloves. No hand hygiene between the removal of the old dressing and application of new gloves was observed. LVN 2 cleaned the wound bed and applied both medication and a clean gauze wrap. LVN 2 removed her gloves and donned new gloves. No hand hygiene was observed. d. LVN 2 directed Resident 381 to turn on his side, opened his brief and removed the old dressing on his coccyx. LVN 2 removed her gloves and donned new gloves. No hand hygiene between the removal of the old dressing and application of new gloves was observed. LVN 2 cleaned the wound bed and applied both medication and a new foam dressing to Resident 381's coccyx. LVN 2 removed her gloves and donned new gloves. No hand hygiene was observed. LVN 2 closed Resident 381's brief. On 9/6/19 at 1118 hours, an interview was conducted with LVN 2. LVN 2 stated hand hygiene was to be performed between each glove change and after performing a dressing change on each area of the Resident's body. LVN 2 verified hand hygiene was not performed after each removal of Resident 381's old dressings, after performing a dressing change to different areas of the resident's body and after each removal of her gloves. LVN 2 stated she should have washed her hands between each dressing change. LVN 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 57 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 she thought a glove change was sufficient when moving from a clean area of the Resident's body (the head) to the hands and to the coccyx. LVN 2 verified these findings. 2. Review of the facility's P&P titled Central Vascular Access device (CVAD) dressing change, revised date 5/2015, showed the catheter insertion site is a potential entry site for bacteria which may cause a catheter-related infection. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures. This expectation included the use of a sterile drape to set up the sterile field, two masks, (one for the nurse and the other for the resident) a sterile, transparent dressing, a sterile measuring tape and sterile gloves. On 9/9/19 at 0811 hours, an observation of Resident 281's external catheter PICC line measurement was conducted with the DCS. The DCS was observed with a measuring tape and donning sterile gloves. The DCS was observed measuring the external catheter length of Resident 281's PICC line without removing the dressing. The puncture site was not visible to the eyes. The DCS was asked how to visualize and measure the correct length for the external catheter when the clean bandage obscured the puncture site and part of the PICC line. The DCS was observed changing her gloves and donning clean, nonsterile gloves. The DCS was observed opening the PICC line dressing. No sterile field was established. No drape was applied to Resident 281. The DSC did not don a mask or ask the resident to turn their head away from the dressing. The DSC, using the same measuring tape, measured the length and provided her measurement. The DSC placed the dressing back onto Resident 281's arm and did not apply a new one. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 58 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 9/9/19 at 1045 hours an interview was conducted with the DCS. The DCS verified she had used sterile gloves when the dressing was not open but had switched to clean gloves prior to opening the PICC line dressing to measure the external catheter length. The DCS verified a sterile field had not been established for the opening of the PICC line dressing. The DCS stated she had not completed a dressing change, but had taped the old dressing back in place and applied a new film dressing over the old one. The DCS verified the above findings. Cross reference to F694, example #2.

F881 SS=E Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 09/24/2019 §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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to implement an Antibiotic Stewardship Program to reduce the risk of unnecessary or inappropriate antibiotic use. * The facility failed to conduct accurate surveillance of incidents of infections as per the McGeer's Criteria (a set of criteria used in long term care facilities to identify if residents' symptoms met the criteria of a true infection). This had the potential for incorrect data being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 59 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 reported to the Infection Control Committee due to not accurately identifying infections. * The facility failed to develop an action plan to address the increase in the number of incidents of HAI. This had the potential for the spread of infections in the facility. Findings: According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. On 9/10/19 at 0744 hours, an interview and concurrent review of the facility's antibiotic stewardship program was conducted with the ADCS who was also the facility's designated Infection Control Nurse. The ADCS stated she was responsible for the facility's infection control and antibiotic stewardship program. The ADCS stated the facility utilized the McGeer's Criteria to define infection surveillance activities. 1. Review of the facility's infection surveillance and logs from March to June 2019 showed there were no incidence of antibiotic use not meeting the McGeer's criteria in the facility. The ADCS stated if the onset of symptoms of infection occurred 48 hours after admission, the infection was considered as HAI. The ADCS stated these included antibiotics prescribed for prophylaxis use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 60 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Review of the Surveillance Data Collection Forms showed the incidents of infections were not accurately classified as HAI as per the McGeer's criteria. For example, review of Resident 21's Surveillance Data Collection Form dated 8/23/19, showed Resident 21 was prescribed an antibiotic for a UTI (urinary tract infection) without an indwelling catheter. Resident 21 had a microbiologic test result of at least 100,000 cfu/ml of any organism; however, there were no other symptoms per the McGeer's criteria. Resident 21's infection was identified as a HAI. Review of the QA (Quality Assurance) - July 2019 (summary of incidents of infections reported to QA) showed there were 11 HAIs eight UTIs and one respiratory; however, review of the infection line listing showed there were 15 HAIs. The ADCS verified she did not report the correct number of incidence of infections. Further review showed eight out of 15 did not have symptoms meeting the McGeer's Criteria. For example, Resident 286 was prescribed an antibiotic for a UTI with indwelling catheter on 7/11/19. Resident 286 did not have any symptoms and a urinary specimen culture with at least 100,000 cfu/ml of any organism per the McGeer's Criteria. Resident 286's signs/symptoms was identified as a HAI. Review of the line listing for June 2019 showed there were 12 HAIs. However, eight of 12 did not have symptoms meeting the McGeer's Criteria. Further review showed an incorrect criteria was used for the residents' symptoms and reason for antibiotic use. For example, Resident 287 was prescribed an antibiotic for UTI on 6/30/19. Review of the Surveillance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 61 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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 Data Collection Form dated 6/30/19, showed criteria for Other Infections was utilized. Resident 287 had a fever and a urinary specimen culture with at least 100,000 cfu/ml of any organism. The ADCS stated the licensed nurses filled out the Surveillance Data Collection Form based on the residents' symptoms and the reason for the antibiotic use. The ADCS stated she based her line listing on the forms utilized by the licensed nurses, even though they were incorrect. Review of the QA - May 2019 showed there were nine HAIs for May 2019; however, review of the line listing showed there were eight HAIs and two symptoms of infection not meeting the McGeer's Criteria. The ADCS stated she identified all infections whose onset of symptoms occurred 48 hours after admission as HAIs, even though these symptoms did not meet the McGeer's Criteria. When asked why, the ADCS stated if the infection was not a CAI, then it was a HAI. This was the reason why there were no incidents of infections not meeting the McGeer's Criteria reported to the infection control committee and the QA. Review of the Infection Control Minutes for April 2019 showed there were 11 HAIs reported for the month. However, review of the line listing showed there were 10 HAIs and one incident of infection whose symptoms did not meet the McGeer's Criteria. Further review showed six of 11 incidents of infections did not have symptoms meeting the McGeer's Criteria. For example, Resident 288 was prescribed antibiotics for pneumonia on 4/28/19, however, review of the Surveillance Data Collection Form dated 4/28/19, showed Resident 288 had an oxygen saturation of less than 94%, but did not have a chest x-ray demonstrating pneumonia or the presence of new infiltrate and at least one McGeer's constitutional Criteria. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 62 of 63 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 (X3) DATE SURVEY COMPLETED A. BUILDING: ___________ B. WING: _______________ 09/10/2019 555763 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN JUAN HILLS HEALTHCARE CENTER 31741 Rancho Viejo Rd San Juan Capistrano, CA 92675 (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. Review of the QA - July 2019 showed there were eight HAIs for UTIs for the month of July 2019, an increase from the previous months' incidents of UTIs. When asked what the action plan was for the increase in the incidents of UTIs in the facility for July 2019, the ADCS had no answer. When asked if she provided education to staff related to infection control for the UTIs, the ADCS stated no. The ADCS verified the above findings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3N6711 Facility ID: CA0600001680 If continuation sheet 63 of 63