Health inspection·August 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, closed medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of four sampled residents (Resident 1). * The facility failed to ensure the results of Resident 1's CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and urinalysis test were promptly reported to Resident 1's physician. This failure had the potential for the resident not to receive the necessary care and services to maintain their highest physical well-being and potentially delaying necessary care and treatment. Findings: Review or the facility's P&P titled Laboratory Services and Reporting reviewed/revised 12/19/22, showed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The policy explanation and compliance guidelines section showed the facility is responsible for the timeliness of the services. Promptly notify the ordering physician, physician assistant nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. a. Closed medical record review for Resident 1 was initiated on 8/19/25. Resident 1 was admitted to the facility on [DATE], and discharged on 8/16/25. Review of Resident 1's H&P examination dated 12/7/24, showed the resident had the capacity to make medical decisions. Review of Resident 1's Order Summary Report dated 8/21/25, showed a physician's order dated 8/3/25 at 1830 hours, for stat CBC, BMP , urine analysis with culture and sensitivity. To start IV hydration 60 cc for 48 hours. Review of Resident 1's Lab Results Report dated 8/4/25, showed the following CBC report information: - Collection date: 8/4/25 at 1145 hours;- Received date: 8/4/25 at 1654 hours; and- Reported date: 8/4/25 at 2231 hours.In addition, the report showed Resident 1's WBC (White Blood Count) was 20.3 and the reference range was 4.5-11. However, further closed medical record review for Resident 1 failed to show documented evidence the CBC test results were promptly reported to Resident 1's physician. b. Review or the facility's P&P titled Urine Sample Collection reviewed/revised 12/19/22, showed to promote accurate diagnosis and treatment of a resident's medical conditions, staff shall obtain urine samples in accordance with established standards of practice. The policy explanation and compliance guidelines section showed to notify physician of results, and file results in the resident's medical record. Review of Resident 1's Lab Results Report dated 8/5/25, showed the following urinalysis report information: - Collection date: 8/4/25 at 0500 hours;Received date: 8/5/25 at 1435 hours; and- Reported date: 8/5/25 at 1917 hours.In addition, the report showed Resident 1's urine WBC was 6-10 and the reference range was negative. The report also showed there was moderate bacteria and the reference range was none seen. However, further closed medical record review for Resident 1 failed to show documented evidence the urinalysis test results were promptly reported to Resident 1's physician. c. Review of Resident 1's Lab Results Report dated 8/5/25, showed the following BMP report information: - Collection date: 8/5/25 at 1500 hours;- Received date: 8/5/25 at 1952 hours; and- Reported date: 8/5/25 at 2229 hours.In addition, the report showed Resident 1's BUN was 57 mg/dl and the reference range was 9-23 mg/dl. However, further closed medical record review for Resident 1 failed to show documented evidence the BMP test results were promptly reported to Resident 1's physician. On 8/21/25 at 1203 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 verified Resident 1's CBC, urinalysis and BMP results were not promptly reported to the resident's physician. LVN 2 acknowledged there was no documentation to show Resident 1's physician was informed promptly regarding the resident's abnormal CBC results. LVN 2 verified the resident's urinalysis laboratory results fell outside of the clinical reference range and was not promptly reported to Resident 1's Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555308 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician. LVN 2 stated the licensed nurse should have called the laboratory right away and reported the abnormal laboratory results to Resident 1's physician. On 8/21/25 at 1353 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified there was no documentation to show Resident 1's physician was informed promptly regarding the resident's abnormal CBC results. RN 1 verified the above findings. RN 1 stated the licensed nurse should have called Resident 1's physician right away and document the notification. On 8/21/25 at 1645 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Event ID: Facility ID: 555308 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure the laboratory tests for one of four sampled residents (Resident 1) was performed as ordered. * The facility failed to ensure Resident 1's physician's order for stat CBC, urinalysis, and BMP laboratory tests were completed in a timely manner. This failure posed the risk for Resident 1 not receiving the appropriate treatment, which could significantly impact the resident's well-being. Findings: According to the Fundamentals of Nursing 10th edition, under the Types of Orders section, a stat order is also a single order, but it is carried out immediately. Review or the facility's P&P titled Laboratory Services and Reporting revised 12/19/22, showed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The policy explanation and compliance guidelines section showed the facility is responsible for the timeliness of the services. Review or the facility's P&P titled Urine Sample Collection revised 12/19/22, showed to promote accurate diagnosis and treatment of a resident's medical conditions, staff shall obtain urine samples in accordance with established standards of practice. Closed medical record review for Resident 1 was initiated on 8/19/25. Resident 1 was admitted to the facility on [DATE], and discharged on 8/16/25. Review of Resident 1's H&P examination dated 12/7/24, showed the resident had the capacity to make medical decisions. Review of Resident 1's Order Summary Report dated 8/21/25, showed a physician's order dated 8/3/25 at 1830 hours, for stat CBC, BMP, and UA with C&S. Review of Resident 1's Lab Results Report dated 8/4/25, showed the CBC collection date and time was on 8/4/25 at 1145 hours. Review of Resident 1's Lab Results Report dated 8/5/25, showed the urinalysis collection date and time was on 8/4/25 at 0500 hours. Review of Resident 1's Lab Results Report dated 8/5/25, showed the BMP collection date and time was on 8/4/25 at 1145 hours. However, further closed medical record review for Resident 1 failed to show documented evidence the stat CBC, urinalysis, and BMP were collected in a timely manner. On 8/21/25 at 1203 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated the licensed nurse should have collected the urine right away or as soon as possible. LVN 2 stated the licensed nurse should have called the laboratory right away because the physician's order for Resident 1's laboratory tests were ordered as a stat order. On 8/21/25 at 1353 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 acknowledged there was no documentation the laboratory was called right away to draw/collect the resident's ordered stat laboratory tests. RN 1 stated the licensed nurse should have endorsed to the next shift if the laboratory was called and to follow up to the laboratory staff. On 8/21/25 at 1645 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555308 If continuation sheet Page 4 of 4