Inspection·November 17, 2023

F 0554 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 22's MDS dated [DATE], showed Resident 22 was cognitively intact and with an impairment to one of the upper extremities. Residents Affected - Few Review of the resident's medical record failed to show a physician's order for the clobetasol cream medication, nor an assessment was completed for Resident 22 to safely self-administer medications. Review of the plan of care failed to show a care plan problem was developed to address Resident 22's self-administration of the clobetasol cream medication. On 11/16/23 at 1020 hours, an interview and concurrent medical record review for Resident 22 was conducted with the DON. When asked how the residents were evaluated to self-administer medication, the DON stated a self-administration assessment should be completed if the resident wished to self-administer their medications, and the resident had the cognitive and physical ability to self-administer their medications. The DON stated if a resident was assessed to be able to self-administer her medication, there should be a physician's order for the resident's self-administration of medication, and this should be addressed in the resident's care plan. The DON verified there was no assessment conducted for Resident 22 to self-administer medications, no physician's order to self-administer medications, and no care plan to address the resident's self-administration of medication. 2. On 11/14/23 at 0853 hours, an observation and concurrent interview with Resident 580 was conducted in Resident 580's room. Resident 580 was observed with one bottle of Systane (eye drop lubricant) medication left unattended at the resident's bedside. Resident 580 stated she used Systane eye drops four times daily and brought the eye drop medication from home. Medical record review for Resident 580 was initiated on 11/14/23. Resident 580 was admitted to the facility on [DATE]. Review of the Internal Medicine History and Physical/Progress Note dated 11/10/23, signed by the physician, showed Resident 580 was cognitively alert. Further review of Resident 580's medical record showed there was no physician's order, assessment, and care plan for self-administration of the observed medication. On 11/14/23 at 0905 hours, an interview and concurrent medical records review with LVN 3 was conducted. LVN 3 verified Resident 580 had one bottle of Systane eye drops left unattended at bedside. LVN 3 stated the medication should not be left unattended at the bedside to ensure the residents received the medication and was not taken by unauthorized personnel. In addition, LVN 3 stated the medication left at the bedside needed a physician's order. LVN 3 verified Resident 580 did not have a physician's order for Systane eye drop, assessment, and care plan for self-administration of medications. On 11/15/23 at 0849 hours, an interview with the DON was conducted. The DON stated the medications should not be left unattended at the bedside if there were no physician's order, assessment, and monitoring in place for self-administration of the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 2 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 8) and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. This failure had the potential for Resident 8 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Holds and Returns revised 3/2017 showed prior to transfer or therapeutic leave, the residents or resident representatives will be informed in writing of the bed-hold and return policy. Closed medical record review for Resident 8 was initiated on 11/15/23. Resident 8 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of the Resident 8's Progress Note showed a nursing entry dated 11/4/23 at 1932 hours, showing Resident 8 was transferred to the acute care hospital. Review of Resident 8's the Bed Hold Notification Informed Consent dated 10/2/23 at 1716 hours, showed, You have the option of requesting a seven-day bed hold to keep bed vacant and available for return to this facility. Non- medical beneficiaries are responsible for reasonable cost not to exceed the beneficiaries' daily room rate. Insurance may or may not cover such charges. Medicaid will cover the cost of the bed hold if the resident's share of cost has been satisfied for the month, unless we receive written notice from the attending physician that the stay in the acute hospital is expected to exceed seven days. If you desire this option, you must notify the facility within 24 hours of transfer. Under the section titled Confirmation of Transfer and Bed Hold Provision did not show any entry. Review of the closed medical records for Resident 8 failed to show documentation Resident 8 and/or their representative were provided with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital on [DATE]. On 11/16/23 at 0938 hours, an interview and a concurrent closed medical record review for Resident 8 was conducted with the DON. The DON verified Resident 8 and/or their representative were not provided with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 3 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plan for one of the 12 final sampled residents (Resident 332). * The facility failed to implement the plan of care to provide the padded side rails for Resident 332. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 332. Findings: On 11/14/23 at 0901 hours, and 11/16/23 at 1400, 1411, and 1430 hours, Resident 332 was observed lying in bed with a right side hand assist rail elevated. The hand assist rail was not padded. Medical record review for Resident 332 was initiated on 11/14/23. Resident 332 was admitted to the facility on [DATE]. Review of Resident 332's Order Summary Report showed the following physician's orders: - On 11/9/23, to administer lacosamide (antiseizure medication) 100 mg 1/2 tablet by mouth two times a day; and - On 11/14/23, to use the right hand-assist rails for bed mobility and repositioning. Review of Resident 332's care plan problem addressing the risk for recurrent seizure episodes due to seizure disorder dated 11/9/23, showed the interventions including to provide the padded side rails. On 11/16/23 at 1411 hours, an interview was conducted with LVN 4. LVN 4 verified the above findings. When asked about Resident 332's hand-assist rail, LVN 4 verified the assist rail was not padded. LVN 4 stated Resident 332 used the assist rail to help with turning and repositioning. On 11/16/23 at 1444 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated Resident 332 should be provided with the padded side rails as shown in Resident 332's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 4 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of 12 final sampled residents (Resident 6). Residents Affected - Few * The facility failed to provide activities for Resident 6 to meet the resident's identified interests. Resident 6 was provided with the children's coloring page, connect the dot activity sheet, and [NAME] sheet. This failure had the potential for Resident 6 to experience feelings of social isolation and frustration. Findings: On 11/14/23 at 1051 hours, Resident 6 was observed sitting in the activity room. When asked about the activities provided by the facility, Resident 6 stated the activities provided to her and the residents in the facility were for children. Resident 6 stated she was provided with children's coloring pages, and she wanted more productive activities. Medical record review for Resident 6 was initiated on 11/14/23. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Internal Medicine History and Physical/ Progress Note dated 10/9/23, showed Resident 6 had capacity to make decision. Review of Resident 6's Activity Assessment Form dated 10/6/23, showed Resident 6 required assistance for her preferred interests. The assessment form showed the boxes for creative expressive on art history, craft project, crochet/ knit, drawing/ painting, poetry writing, and wood working were not checked. The assessment form did not show arts and crafts were one of Resident 6's activity preferences. Review of Resident 6's plan of care showed a care plan problem dated 10/10/23, to address Resident 6's attendance to activities of choice and self-initiated leisure activities. The goal was for Resident 6 to participate in three activities per week such as listening to music, watching police shows, seeing her daughter, seeing therapy dogs, playing bingo, going outside, and socializing with friends and staff. The plan of care did not include arts and crafts as Resident 6's activity preferences. Review of Resident 6's Attendance Participation Form for October and November 2023 showed Resident 6 was provided with arts/creativity/cooking, bingo, board/card games, exercise, family/friend/visitor visits, movies, music/radio, outdoor/outings, pets/ pet therapy, reading books/magazines, salon/ nails, sensory/aroma therapy, socialization, and television. On 11/16/23 at 0948 hours, an interview and concurrent medical record review and facility document review was conducted with the Activities Assistant. The Activity Assistant verified the above findings. When asked about the activity assessment, the Activity Assistant stated she would go to the room and asked the resident questions regarding activities such as music, pets, TV, and other preferred activities. When asked about the activities provided to the residents, the Activity Assistant stated she provided the Daily Chronicle printout. When asked what activities were provided to Resident 6, the Activity Assistant stated she did arts and crafts with Resident 6. The Activity Assistant showed the arts and crafts included a pumpkin color by number, popcorn [NAME], and a turkey (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 5 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few connect-the-dot/number sheet. The Activity Assistant stated she gave the popcorn [NAME], pumpkin color by number and turkey connect-the-dots/ number sheets to Resident 6 and Resident 6 was not into it. The Activity Assistant stated Resident 6 told her those activity sheets were for children, but the Activity Assistant stated she still gave the activity sheets to Resident 6. When asked if she gave Resident 6 another activity sheets for adults, the Activity Assistant answered no. When asked why Resident 6 was given arts and crafts activities when it was not one of Resident 6's preferred activities as per the assessment form and plan of care, and Resident 6 did not like the arts and crafts sheets, the Activity Assistant answered she still gave the arts and crafts sheets because she had to follow what was on the activity calendar. On 11/17/23 at 0931 hours, an interview and concurrent medical record review and facility document review was conducted with the Activities Director/Central Supply. The Activities Director/Central Supply verified the above findings. The Activities Director stated they had to ensure the activities provided to the residents matched the cognitive ability of the residents, and not just to follow the activity calendar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 6 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure monitoring of the neurological status was conducted after a fall with head injury for one of 12 sampled residents (Resident 17). This failure had the potential for Resident 17 to not receive the necessary care and services. Residents Affected - Few Findings: Review of the facility's P&P titled Falls Management Program revised 2019 showed the facility is to provide residents with hazard free environment, adequate supervision, and reduce risk factors leading to falls and injury. Further review of the the P&P showed neuro check will be initiated by the licensed nurse for unwitnessed fall and when there was identified head injury. Review of the facility's document titled Neurological Evaluation Flowsheet revised 11/2011 showed the following frequency to perform the neuro checks: - Every 15 minutes times for 1 hour; - Every 30 minutes for 2 hours; - Every 1 hour for 2 hours; and, - Every shift for 72 hours. Medical record review for Resident 17 was initiated on 11/15/23. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Progress Note dated 10/20/23 at 1320 hours, showed Resident 17 had a witnessed fall on walkway outside the facility, which was witnessed by a family member. The family member observed Resident 17 falling out of the wheelchair onto her left side. Further review of the Progress Note showed Resident 17 had a small abrasion on left temple (located on the side of the head behind the eye between the forehead and the ear). Review of Resident 17's medical record did not show neurological evaluation was conducted after the fall incident on 10/20/23, with injury to the head. On 11/16/23 at 0909 hours, an interview and concurrent medical record review for Resident 17 was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 stated the neurological evaluation should have been completed after the fall incident with head injury. On 11/16/23 at 1226 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 7 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for two of 12 final sampled residents (Residents 1 and 581). Residents Affected - Few * The facility failed to ensure Resident 1's nebulizer mask (a mask connected to a nebulizer machine used to deliver a liquid/ solution medication via inhalation directly into the lungs) was stored in the set-up bag when not in use and changed weekly as per the facility's P&P. In addition, the facility failed to ensure Resident 1's nasal cannula tubing was stored in the set-up bag when not in use as per the facility's P&P. * The facility failed to ensure Resident 581 received oxygen as ordered. These failures had the potential for these residents to not receive appropriate respiratory care, and for increased risks of infection and respiratory distress. Findings: 1. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised November 2011. under the Infection Control Consideration Related to Oxygen Administration section, showed to change the oxygen cannula and tubing every seven days, or as needed, and to keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. The Infection Control Consideration related to Medication Nebulizers/ Continuous Aerosol section showed to store the circuit in plastic bag, marked with date and resident's name, between uses. On 11/14/23 at 0853 hours, during the initial tour of the facility, Resident 1 was observed in bed, with oxygen on via nasal cannula. A nebulizer mask was observed inside an open drawer, not stored inside a set-up bag. Three set-up bags were observed inside the drawer dated 10/21, 10/28, and 11/4/23. A nasal cannula connected to a portable oxygen tank in Resident 1's wheelchair was observed not stored inside the set-up bag. Resident 1 stated she was on continuous oxygen and had to use the nasal cannula connected to the portable oxygen tank when she used the bathroom. Resident 1 stated the nurses administered her breathing treatment using the nebulizer mask, but she had to turn off the nebulizer mask when it was done and placed the nebulizer mask inside the drawer. Medical record review was initiated on 11/14/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following physician's orders dated 5/2/23: - To administer oxygen at four liters per nasal cannula continuously every shift; - To change tubing every night shift every Saturday; - To administer budesonide inhalation solution (corticosteroid medicaiton) 0.5 mg/2 ml two times a day; and - To administer ipratropium-albuterol (corticosteroid medication) solution 0.5 - 2.5 mg/ml four times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 8 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0695 Review of Resident 1's MAR showed Resident 1 was administered the following: Level of Harm - Minimal harm or potential for actual harm - Budesonide inhalation solution was administered from 11/1 to 11/15/23, at 0900 and 1700 hours, - Ipratropium-albuterol was administered from 11/1 to 11/15/23 at 0900, 1300, 1700, and 2100 hours; and Residents Affected - Few - Oxygen was administered from 11/1 to 11/15/23 on the day, evening, and night shifts. On 11/14/23 at 1122 hours, an observation for Resident 1 and concurrent interview was conducted with LVN 4. Resident 1 was observed in bed receiving oxygen via nasal cannula. A nebulizer mask was observed inside an open drawer, not stored inside a set-up bag. Three set-up bags were observed inside the drawer dated 10/21, 10/28, and 11/4/23. A nasal cannula observed connected to a portable oxygen tank in Resident 1's wheelchair and was observed not stored inside the set-up bag. LVN 4 verified the above findings. On 11/16/23 at 0848 hours, Resident 1 was observed in bed, with oxygen on via nasal cannula. The nasal cannula connected to a portable oxygen tank in Resident 1's wheelchair was observed not stored inside the set-up bag. Another set-up bag containing a nasal cannula tubing was observed on the bathroom floor. On 11/16/23 at 0852 hours, an observation for Resident 1 and concurrent interview was conducted with LVN 4. LVN 4 verified the above findings. On 11/16/23 at 1026 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. The DON stated the nasal cannula tubing and nebulizer mask and tubing should be changed weekly every Saturday by the night shift nurses. The DON stated the nasal cannula tubing and nebulizer tubing should be labeled with the date when they were changed. The DON stated the set-up up bag should be labeled with the resident name, room number, and date when the nasal cannula tubing or nebulizer tubing was changed. The DON stated the nasal cannula tubing and the nebulizer mask and tubing should be stored in the set-up bag when not in use. 2. Medical record review for Resident 581 was initiated on 11/14/23. Resident 581 was admitted to the facility on [DATE]. Review of the Admission/Medicare-5 Day MDS dated [DATE], showed Resident 581 with a BIMS score of 11 (according to the MDS RAI Manual, a score of 8-12 indicates resident has moderate impairment). Further review of Resident 581's medical record showed the physician's orders for continuous oxygen to be administered at 2 liters per minute via nasal cannula every shift for COPD (Chronic Obstructive Pulmonary Disease - medical condition constricting the airways in the lungs and cause difficulty breathing). Review of Resident 581's Medication Administration Record from 11/1 to 11/14/23, showed Resident 581 was administered oxygen at 2 liters per minute via nasal cannula continuously every shift for COPD during the day shift (0700-1500 hours), evening shift (1500-2300 hours), and night shift (2300-0700 hours). Review of the resident's care plan titled Ineffective Airway Clearance R/T COPD, Hx of PNA, OSA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 9 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0695 dated 11/1/23, showed interventions to administer oxygen as ordered. Level of Harm - Minimal harm or potential for actual harm Review of the resident's care plan titled Need Special Care R/T Oxygen Use at Risk for Potential Complications such as Oxygen Toxicity dated 11/1/23, showed the intervention to observe for signs/symptoms of oxygen toxicity such as tachypnea (breathing rate that is higher than the normal breathing rate), substernal pain, and dizziness; physiologic effects include atelectasis (a collapse of the whole lung or an area of the lung), ciliary dysfunction (abnormal function impairs the ability of [NAME] to function in a coordinated manner, impairing mucociliary clearance and causing chronic upper and lower respiratory inflammation), and nitrogen washout; in carbon dioxide retainers, hypoventilation, somnolence (a state of drowsiness or strong desire to fall asleep). Residents Affected - Few On 11/14/23 at 0930 hours, an observation and concurrent interview with Resident 581 was conducted. The oxygen concentrator was observed showing the resident received oxygen at 3 liters per minute. Resident 581 stated she received continuous oxygen and used oxygen at home. On 11/14/23 at 1139 hours, an interview and concurrent record review was conducted with LVN 3 in Resident 581's room. LVN 3 verified Resident 581 was on oxyen at 3 liters per minute via nasal cannula. LVN 3 stated Resident 581's physician's order for continuous oxygen at 2 liter per minute. Furthermore, LVN 3 verified the staff did not follow Resident 581's physician's order for oxygen and should follow the physician's orders. On 11/15/23 at 0849 hours, an interview with the DON was conducted. The DON stated the oxygen levels were based on the physician's orders and the facility would need an order from the physician to titrate oxygen levels to 3 liters per minute in order to administer oxygen at 3 liters per minute. The DON further stated the physician's orders for oxygen should be followed to ensure the residents did not receive an excessive amount of oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 10 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, Residents Affected - Few * The facility failed to ensure the narcotic disposition bin was securely locked and sealed. Furthermore, the narcotic disposition bin included whole pills of disposed controlled medications not fully dissolved. * The facility failed to ensure the controlled medications signed out of the controlled medication report was accurately reflected on the eMAR for one nonsampled resident (Residents 9). * The facility failed to ensure LVN 1 administered albuterol-ipratropium solution as ordered for one of 12 final smapled residents (Resident 1). These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the facility's P&P titled Controlled Medication Disposal dated 1/2013 showed Schedule II-V controlled substances remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the Director of Nursing or designated facility registered nurse in conjunction with the pharmacist. On 11/15/23 at 0958 hours, an observation and concurrent interview with the DON was conducted in the medication room. The DON showed the medication disposition bin in the medication room. The lid of the bin was not securely sealed or locked; anyone in the medication room could lift the lid open and have access to all the pills of disposed controlled medications not fully dissolved inside the medication disposition bin. The DON stated the facility's process was for the disposed controlled and non-controlled medications be placed in the disposed bin in the medication room until the bin was picked up for incineration. The DON acknowledged the narcotic disposition bin was not sealed and the disposed controlled medication tablets were still intact. The DON stated the medications disposition bin was locked inside the medication room. The DON further acknowledged any staff who had access to the medication room could access to the medications inside the disposed medications bin. On 11/16/23 at 0904 hours, during a telephone interview with the facility Consultant Pharmacist, he stated he would work with the facility to come up with a way to keep the disposed controlled drugs secure. 2. Review of the facility's P&P titled Controlled Medications dated 4/2008 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): - Date and time of administration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 11 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0755 - Amount administered. Level of Harm - Minimal harm or potential for actual harm - Signature of the nurse administering the dose on the accountability record at the time the medication is removed from supply. Residents Affected - Few - Initials of the nurse administering the dose on the MAR after the medication is administered. Review of the facility's P&P titled Medication Administration - General Guidelines dated 10/2017 showed the individual who administers the medication dose records the administration on the resident's MAR directly after the dose is given. According to the United States Drug Enforcement Administration (DEA), hydrocodone combination products including hydrocodone-acetaminophen (pain medication for moderate to severe pain) is categorized as a Schedule II controlled medication. The DEA labels Scheduled II medications as having a high potential for abuse and are considered dangerous. Review of Resident 9's medical record showed the resident was admitted to the facility on [DATE]. Review of the Order Summary Report showed the physician's order dated 10/27/23, for hydrocodone-acetaminophen (opioid analgesic) 5-325 mg one tablet every four hours as needed for severe pain. Review of Resident 9's count sheet titled Skilled Nursing Pharmacy Antibiotic or Controlled Drug Record showed Resident 9's hydrocodone-acetaminophen 5-325 mg tablet was signed out on 11/1/23 at 0600 hours, but was not documented as administered on the eMAR. On 11/14/23 at 1510 hours, an interview and concurrent medical record review was conducted with LVN 3 at Team 2 Medication Cart. LVN 3 verified Resident 9's hydrocodone-acetaminophen 5-325 mg tablet signed out on 11/1/23 at 0600 hours, was not documented as administered. 3. Review of the facility's P&P titled Medication Administration - General Guidelines dated 10/2017 showed medications are administered in accordance with written orders of the attending physician. Review of Resident 1' medical record was initiated on 11/14/23. Resident 1 was admitted on [DATE]. Review of Resident 1's order summary dated 5/2/23, showed showed an order for ipratropium 0.5 mg/albuterol solution 2.5 mg/3 ml 3 ml by oral inhalation four times a day for COPD. On 11/14/23 at 0831 hours, a medication pass observation for Resident 1 was conducted with LVN 3. LVN 3 prepared and administered Resident 1's medications which included the following: - Probiotics (acidophilus/pectin) one capsule (used to maintain or improve the good bacteria (normal microflora) in the body). - Enteric coated aspirin (used to lowers your risk of a heart attack, stroke, or blood clot) 81 mg one tablet. - Budesonide inhalation suspension 0.5 mg/2 ml inhalation - Furosemide (diuretic medication) 40 mg one tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 12 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0755 - Mucinex (to reduce chest congestion) 600 mg Extended Release 12 hour one tablet Level of Harm - Minimal harm or potential for actual harm - Olopatadine HCL 0.2% eye solution (to treat itching of the eye caused by a condition known as allergic conjunctivitis [pink eye]) one drop in each eye Residents Affected - Few - MVI with minerals (supplement) one tablet - Zenpep (pancreatic enzymes, to help body use fats, proteins, and sugars from food) one capsule On 11/14/23 at 1235 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 verified she did not administer Resident 1's 0900 hours dose of ipratropium 0.5 mg/albuterol solution 2.5 mg/3ml. She stated it was documented as administered by mistake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 13 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 17) was free from unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure nonpharmacological interventions were implemented for depression behaviors exhibited by Resident 17. This failure had the potential to place the resident at risk for receiving unnecessary medications and increased risk of serious medication adverse reactions. Findings: Review of the facility's P&P titled Use of Psychotropic Medication use dated 6/2021 showed in part, a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics, and antidepressants . Facility should involve the resident or the resident's representative(s) in the discussion of potential no-drug and medication interventions to address the management of behaviors and the involvement should be documented in the resident's medical records . Facility staff should document the number and/or intensity of symptoms and the resident's response to staff intervention. Medical record review for Resident 17 was initiated on 11/16/23. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's physician's orders dated 10/19/23, showed the following orders: - Wellbutrin SR Oral Tablet Extended Release 12 Hour 150 mg one tablet by mouth two times a day for depression manifested by persistent expression of helplessness. - CeleXA Oral Tablet 10 mg one tablet by mouth one time a day for depression manifested by persistent expression of hopelessness. Review of Resident 17's medical record showed non-pharmacological interventions were not identified or documented as an option to be implemented. Further review also showed the provider's documenting Resident 17 has been on the two antidepressants for a long time, no change needed. On 11/16/23 at 1422 hours, an interview and concurrent medical record review with the DON was conducted. The DON verified there was no non-pharmacological intervention implementation documented. On 11/16/23 at 1507 hours, an interview and concurrent medical record review with LVN 1 was conducted. LVN 1 verified Resident 17 was receiving Wellbutrin SR and Celexa for depression. LVN 1 stated the resident had not exhibited any behavior during her shifts and non-pharmacological intervention has not been needed. LVN 1 also verified there was no non-pharmacological interventions documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 14 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility P&P review, the facility failed to store medications, biologicals, and medical supplies in a safe manner. The facility also failed to replace three of four E-Kits (emergency medications in a portable sealed containers) within 72 hours of opening as required by the facility's P&P. * The facility failed to ensure the expired medications and medical supplies were not available for resident use. This failure had the potential for the outdated medications and medical supplies to be accidentally administered and/or used and the IV medical supplies not maintaining sterility (free from germs). * The facility failed to replace the IV, controlled medication, and oral E-kits within 72 hours of opening the kits. These failures had the potential for the medications not to be available when needed for the residents, resulting in poor resident outcomes. Findings: 1. Review of the facility's P&P titled Storage of Medications dated 4/2008 showed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if current order exist. a. On 11/14/23 at 1451 hours, an inspection of Team 2 Medication Cart and concurrent interview was conducted with LVN 1. The following was observed: - Pravastatin Sodium (medication used to lower cholesterol and fat in the blood) in the original container labeled for a resident who had expired on 4/18/23. - insulin lispro injection Kwikpen (medication used to lower blood sugar) was opened on 10/1/23. - Glucose 15 oral glucose gel (medication used to treat low blood sugar level) had expired on 11/21. LVN 1 stated insulin lispro was only good for 28 days at room temperature, and it should be discarded. LVN 1 verified the outdated medications. b. On 11/14/23 at 1543 hours, an inspection of the treatment cart and concurrent interview was conducted with the MDS nurse. The following was observed: - Solosite wound gel 3 oz (hydrogel wound gel used to create a moist environment for treatment of minor conditions and skin tear) had expired on 8/22. - one Precise disposable skin staple remover (to remove the staples of various surgical skins) had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 15 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0761 expired on 12/21. Level of Harm - Minimal harm or potential for actual harm - one Collagen hydrogel wound dressing 3 oz (promotes dermal remodeling and wound healing in a moist environment) had expired on 4/23. Residents Affected - Few - 63 Chloraprep one-step swab sticks (used for disinfection of the skin prior to invasive medical procedures) had expired on 10/22. The MDS nurse verified the above findings. c. On 11/14/23 at 1558 hours, an inspection of the IV (intravenous Medications) cart and concurrent interview was conducted with the DON. The following was observed: - 2 opened partially used IV Stat kits The DON verified the above findings and stated any item not used in the opened kits should be removed from cart. 2. Review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits dated 8/2014 showed in parts, emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. An emergency supply of medications including emergency drugs, antibiotics, controlled substances, and products for infusion is supplied by the provider pharmacy in limited quantities in portable, sealed containers that are in compliance with applicable state regulations . If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. On 11/14/23 at 1530 hours, an inspection of the medication room and concurrent interview was conducted with the DON. Review of the E-Kits and the corresponding logs showed the following: - IV E-Kit was opened and used on 11/9/23. - Oral E-Kit was opened and used on 11/10/23. - Controlled medication E-Kit was opened and used on 11/9/23. The controlled medication, IV medication, and oral medication E-Kits were opened/used and not replaced within 72 hours as per the facility's P&P. The DON verified the above findings and stated the opened E-Kits should be replaced within 72 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 16 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and facility document review, the facility failed to ensure the following: 1. Federal regulations related to the oversight of food service operations were followed when the facility did not employ of a full-time qualified individual, defined as 35 hours per week, to manage and oversee food operation services for the skilled nursing facility. 2. The Certified Dietary Manager who was responsible to oversee the main kitchen which produced food for the skilled nursing facility was competent in managing the day-to-day functions of the food services department. Failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 33 residents who received food prepared in the kitchen. Findings: Review of the facility's matrix showed 33 residents who consumed food prepared in the kitchen. 1. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Review of the facility's document titled Personnel Action Form-Payroll dated 6/11/21, showed the RD was hired full-time. Review of the facility's document titled timecard for the RD dated 8/1/23 - 11/17/23, showed the RD worked an average of 26 hours per week. On 11/14/23 at 0835 hours, an interview was conducted with the RD. The RD stated she worked three days a week. On 11/14/23 at 1036 hours, an interview was conducted with the CDM. The CDM stated he was responsible to manage both the main kitchen which produced food for the entire campus and the SNF (skilled nursing facility) satellite kitchen. The CDM stated food prepared for the SNF residents was prepared in the main kitchen and transported to the SNF. On 11/17/23 at 1031 hours, an interview was conducted with the RD. The RD stated she was originally hired full time but when the CDM was hired, she worked only part time. The RD confirmed the CDM was responsible to manage both the main kitchen and SNF satellite kitchen. On 11/14/23 at 1526 hours, an interview was conducted with the Administrator. The Administrator confirmed the RD worked part time. The Administrator stated he was not aware the full-time employment was considered 35 hours per week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 17 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the facility's document titled Director of Food Services signed and dated by the CDM on 6/16/22, showed the primary purpose of Director of Food Services was to assist the RD in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Service Department is maintained in a clean, safe and sanitary manner. The section titled competency evaluation was not completed. During the annual recertification survey from 11/14/23 to 11/17/23, multiple issues were found in the main kitchen, including: inaccurate and missing documentation of cooling for TCS (time/temperature control for safety foods), lack of a thawing process for meats as per the facility's P&P, service of expired food to one resident (Resident 21), inadequate washing of food preparation utensils, refuse was not stored appropriately in the kitchen, lack of hair covering for multiple cooks, kitchen utensils and equipment were not clean, and the dishwashing temperature was not monitored per the manufacturer guidelines. Cross references to F812, examples #1, #2, #3, #5, #6, #7, #8, and F908, example #2. On 11/17/23 at 1452 hours, an interview was conducted with the Administrator. The Administrator was asked how he ensured his managers were competent in their job functions. The Administrator stated he had worked for the facility for only four months. The Administrator stated he had noticed scheduling issues in the kitchen but had not had the opportunity to fully evaluate the competency of the CDM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 18 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, facility document, and P&P review, the facility failed to ensure the kitchen staff had the skill set necessary to safely perform manual dishwashing in the event of an emergency when one of one diet aides was not competent to describe or demonstrate the manual dishwashing process used in an emergency. This failure had the potential for resident dishes to not be washed correctly in an emergency which could lead to sanitation concerns. Findings: Review of the facility's P&P titled How to Clean and Sanitize Pots, Pans, Utensils, and Dishes dated 2019 showed 1) Fill appropriate temperature water to fill lines. Add appropriate amount of detergent and sanitizer. Test and record on Pot and Pan Litmus Test Log. Scrape and flush out food particles. 2) Wash with detergent (100-120 degrees F). Change water every 30 minutes. 3) Rinse (110-120 degrees F). Change water frequently. 4) Sanitize - test with appropriate litmus test strips and leave in sanitizing solution for appropriate contact time. 5) Air dry - do not towel, inspect, and store dry. Review of the facility's document titled Dietary Aide dated 2/1/2021 and 12/21/21 for DA 3 showed the primary purpose of job position is to provide assistance in all food functions as directed/instructed and in accordance with establish food policies and procedure. The job description did not include a completed competency evaluation. Review of the facility's in-service documents titled Class Attendance Roster dated 2/8, 3/31, and 5/16/23, showed the dishwashing procedure was covered in the in-service and DA 3 was in attendance. On 11/15/23 at 0812 hours, an observation of the manual dishwashing process and concurrent interview was conducted with DA 3 using DA 4 as a translator. The CDM was present during the interview. DA 3 was asked to describe the manual dishwashing process to wash resident dishes used in an emergency. DA 3 stated and demonstrated that he scrubbed the dishes, rinsed with water, then sanitized them in a sanitizing solution. The manual dishwashing sink was not filled with detergent to the specified line located on the outside of the sink. DA 3 was using a large pot filled with detergent to wash the dishes. The rinse sink was also not filled with water, DA 3 demonstrated that he rinsed the dishes with water under the faucet. The sanitizing sink was not filled with sanitizing solution to the specified line on the outside of the sink. DA 3 demonstrated that he dipped the dishes into the sanitizing solution to sanitize the dishes. DA 4 was asked to explain to DA 3 he could refer to the poster that explained proper manual dishwashing. DA 3 was asked if he understood the manual dishwashing poster. DA 3 confirmed he understood the poster because it was in Spanish. The surveyor pointed out the wash, rinse and sanitizing sinks were not filled to the specified line with detergent, rinse water or sanitizing solution as the poster indicated. When asked why DA 3 had not set up the three dishwashing sinks according to the poster, DA 3 did not have an explanation. The surveyor then asked DA 3 again to set up the three dishwashing sinks correctly then demonstrate the correct dishwashing process. DA 3 continued to scrub dishes using detergent from the pot that was in the dishwashing sink and rinse the dishes under the water faucet. The CDM asked if DA 3 was doing something wrong. The surveyor asked the CDM if DA 3 was demonstrating the correct manual dishwashing process. The CDM confirmed DA 3 did not demonstrate the correct manual dishwashing process. On 11/16/23 at 0916 hours, a follow-up observation was conducted of the manual dishwashing sink (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 19 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0802 Level of Harm - Minimal harm or potential for actual harm with the CDM present. DA 3 was observed washing dishes in the manual dishwashing sink using the correct process. Using [NAME] 3 as a translator, DA 3 was asked why the manual dishwashing sink was not set up correctly on 11/15/23. DA 3 stated he was late to work on 11/15/23, and did not have time to set up the manual dishwashing sink correctly. The CDM was asked if the correct manual dishwashing procedure must be followed every time. The CDM stated DA 3 made a mistake. Residents Affected - Few On 11/16/23 at 1024 hours, an interview was conducted with the RD. The RD stated she had given multiple in-services on the manual dishwashing and used a translator. On 11/17/23 at 1045 hours, an interview was conducted with the CDM. The CDM was asked how he ensured his employees were competent in kitchen tasks. The CDM stated he performed an annual competency test for all his employees. The CDM stated the last competency evaluation was completed in September of 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 20 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: Residents Affected - Many * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The thawing process for meats was not performed as per the facility's P&P. * The expired food item in the kitchen was not discarded and was consumed by the resident. * One kitchen staff and one maintenance staff did not perform proper hand hygiene in the kitchen. * The handwashing sink was used for duties other than handwashing. * Trash was stored inappropriately in the kitchen. * Two kitchen staff and one non-staff personnel did not don hair or beard coverings in the kitchen. * The kitchen utensils and equipment were not stored or kept in sanitary conditions. * The kitchen utensils were not in good condition. * The dry storage bin was not labeled correctly. * Food was not stored appropriately per the facility's P&P. These failures had the potential to cause foodborne illnesses in a highly susceptible resident population of 33 facility residents who consumed food prepared in the kitchen. Findings: Review of the facility's matrix showed 33 of 34 residents who consumed food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) within two hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) within a total of six hours from 135 degrees F to 41 degrees F or less, (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Review of the facility's P&P titled Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety dated 2018, showed cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety. The Procedure section, showed when cooked PHF or TCS food are not served right away, it must be cooled as quickly as possible using the Two-Stage Method: (a) cool cooked food from 140 degrees F to 70 degrees F within two hours, and (b) then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 21 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours. The facility's P&P also showed to use the Cool Down Log to document proper procedure when cooling down food. Further review of the facility's P&P showed the Ambient Temperature Foods section showed PHF shall be cooled within four hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna; and to use the cool down log for ambient temperature foods. The section Monitoring Temperatures and Cool Down Log showed to note the menu item, date, time, temperature, and cook's initials on the cool down log. Review of the facility's Cooling Monitoring Form revised 05/16 showed when the food reaches 140 degrees F, start recording temperatures on this form, not when it first comes out of the oven. a. On 11/14/23 at 0755 hours, during the initial tour of the kitchen, an observation of the walk-in refrigerator was conducted. A covered metal container containing tuna salad was observed. The tuna salad had a use-by date of 11/13/23 (prepped on 11/10/23). On 11/14/23 at 1035 hours, an observation and concurrent interview was conducted with the CDM. The CDM confirmed the above findings. Review of the Cooling Monitoring Form for November 2023 showed no documented evidence of the cool down process for the tuna salad prepared on 11/10/23. The Cooling Monitoring Form for November 2023 failed to show the initial date, time, and temperature, and final temperature for the tuna salad. On 11/15/23 at 1028 hours, an observation and concurrent interview was conducted with [NAME] 2. [NAME] 2 was observed documenting the cooling process for tuna salad onto the Cooling Monitoring Form. [NAME] 2 verified she made the tuna salad on 11/14/23. Concurrent review of the Cooling Monitoring Form showed [NAME] 2 started the cooling process for the tuna salad at 1240 hours at 38 degrees F. After two hours, at 1440 hours the temperature was 40 degrees F. When asked how the temperature of the tuna salad increased while in the refrigerator, [NAME] 2 could not answer. On 11/16/23 at 0924 hours, an interview and concurrent review of the Cooling Monitoring Form for November 2023 was conducted with the CDM. The CDM verified the tuna salad made on 11/10/23, was not on the Cooling Monitoring Form. On 11/16/23 at 1024 hours, an interview was conducted with the RD. The RD was asked when should the cook document on the Cooling Monitoring Form. The RD stated the cooks should document on the Cooling Monitoring Log when the cooling process was started and as the food was cooling. On 11/17/23 at 1452 hours, the CDM, RD, Administrator, DON, and Clinical Resource RN were notified of the findings. The CDM stated he was not aware tuna needed to be on the cooling log because it was prepared from room temperature. The CDM was notified the ambient cool down process was on the facility's P&P. b. Review of the facility's document titled Cooling Monitoring Form for October 2023 showed the following: - on 10/1/23, for beef tacos, cooling was started at 1100 hours, at 140 degrees F; and at 1300 hours (two hours later), the temperature was 100 degrees F. No cook's initial were documented and no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 22 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 further time or temperature were recorded. Level of Harm - Minimal harm or potential for actual harm - on 10/7/23, for turkey, cooling was started at 1000 hours, at 145 degrees F; and at 1100 hours, the temperature was 120 degrees F. No cook's initial were documented, no further time or temperature were recorded. Residents Affected - Many - on 10/15/23, for beef BBQ, cooling was at 1100 hours at 100 degrees F; and at 1300 hours, the temperature was 40 degrees F. No cook's initial were documented and no further time or temperature were recorded. - on 10/24/23, beef was started cooling at 1900 hours, at 100 degrees F; and at 2030 hours, the temperature was 40 degrees F,. No cook's initial were documented and no further time or temperature were recorded. On 11/16/23 at 0924 hours, an interview and concurrent review of the Cooling Monitoring Form for October 2023 was conducted with the CDM. The CDM stated the Cooling Monitoring Form was for the cooling of hot foods. When asked about the cooling process, the CDM stated the cooling of hot food should start at 140 degrees F; and after two hours, the temperature should be at 70 degrees F. The CDM stated if the temperature was not at 70 degrees, the food item should be reheated once, and cooling should be reattempted. Further review of the Cooling Monitoring Form for October 2023 was conducted with the CDM. The CDM verified the above findings. The CDM verified the cooling process for TCS foods was not monitored correctly. The CDM also verified the cooks did not initial the entries on the Cooling Monitoring Form. When asked how the CDM identified the cook who started the cooling process, the CDM stated he knew each cook's handwriting. 2. Review of the facility's P&P titled Thawing of Meats dated 2018 under Procedure showed thawing meat properly can be done in a refrigerator at 41 degrees F or colder. To allow two to three days to defrost, depending on quantity and total weight of meat. To label defrosting meat with pull and use by date. Review of the facility's P&P titled Procedure for Refrigerated Storage dated 2018 showed frozen food should be left in a refrigerator to thaw. Once thawed, uncooked meat is to be used within two days. On 11/14/23 at 1035 hours, an interview and concurrent observation of the walk-in refrigerator was conducted with the CDM. The following food items were observed: - five 10-lb rolls of thawed ground beef dated 11/8/23 (no additional dates or stickers were observed), - three 11-lb pot roasts with a use by date of 11/17/23 (no additional dates or stickers were observed), - two 10-lb boxes of diced pork dated 11/3/23 (no additional dates or stickers were observed). The CDM verified the above findings. The CDM stated the sticker dates were the dates the facility received the frozen items. The CDM verified the thawed items in the walk-in refrigerator did not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 23 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the date when the items were placed in the walk-in refrigerator. The CDM stated he knew, in his head, the dates when each meat items were placed in the refrigerator for thawing, and when the meats would be used for cooking. When asked, the CDM verified he should label the items when they were taken out of the freezer and placed in the refrigerator. 3. Review of the facility's P&P titled Food Preparation dated 2018 under the section Leftover Foods showed leftover foods are those that have been prepared for a meal and not served. Leftover foods will be stored and served in a safe manner. The section Storage of Leftovers showed to use refrigerated leftovers within 72 hours. On 11/14/23 at 0755 hours, during the initial tour of the kitchen, an observation of the walk -in refrigerator was conducted. A covered metal container with tuna salad was observed. A use-by date of 11/13/23, was observed on the tuna salad. On 11/14/23 at 1035 hours, an observation and concurrent interview was conducted with the CDM. The CDM confirmed the above finding. The CDM stated he had a kitchen staff who was responsible for discarding items past the use-by date. The CDM further stated that staff member was scheduled to arrive at noon. On 11/14/23 at 1222 hours, during a dining observation, Resident 21 was observed eating a tuna salad sandwich in the dining room. On 11/14/23 at 1259 hours, an observation and concurrent interview was conducted with [NAME] 2. [NAME] 2 stated she was responsible for preparing Resident 21's tuna salad sandwich for the lunch meal. When asked about the tuna salad used, [NAME] 2 pulled the container of tuna salad dated with a use-by date of 11/13/23 from the walk-in refrigerator. When asked when the tuna salad was made, [NAME] 2 stated she could not see the label, and grabbed her glasses. After wearing her glasses, [NAME] 2 verified the use by date of the tuna salad was 11/13/23. [NAME] 2 further stated the tuna salad should be discarded and she would make a new batch. On 11/14/23 at 1305 hours the CDM was notified. The CDM stated the tuna salad should be discarded and that there would be a kitchen staff to remove outdated items from the refrigerator. 4. According to the USDA Food Code 2022, Section 2-301.14 When to Wash Food, employees shall clean their hands and exposed portions of their arms . (E) After handling soiled equipment or utensils; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Review of the facility's P&P titled Hand Washing Procedure dated 2018 showed hand washing is important to prevent the spread of infection. The P&P further showed hands needed to be washed when touching trash can or lid. Review of the facility's P&P titled Glove Use Policy dated 2018 showed to wash hands when changing to a fresh pair. Gloves should never be used in place of handwashing. On 11/14/23 at 0935 hours, the maintenance assistance was observed donning gloves to disassemble the ice machine in the SNF kitchen. When asked if there was anything he did prior to donning gloves, the maintenance assistance stated no. The maintenance assistance verified he did not wash his hands prior to donning gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 24 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 11/15/23 at 0948 hours, DA 2 was observed entering the SNF kitchen after taking out the trash. DA 2 was observed putting in a new trash bag liner, then proceeded to remove a clean rack of plates from the dishwasher. DA 2 was not observed to wash his hands. When asked, DA 2 stated he should have washed his hands after he returned from taking out the trash. DA 2 was observed to wash his hands at this time. 5. According to the USDA Food Code 2022, Section 5-205.11 Using a Handwashing Sink, (A) a handwashing sink shall be maintained so that it is accessible at all times for employee use, (B) a handwashing sink may not be used for purposes other than handwashing. On 11/14/23 at 1259 hours, [NAME] 3 was observed rinsing a knife and wire whisk in the handwashing sink. [NAME] 3 then proceeded to place the knife and whisk back in operation for the next usage. When asked, [NAME] 3 stated he should have cleaned and sanitized the knife and whisk at the dishwashing station. [NAME] 3 further stated the handwashing sink was for handwashing only. On 11/14/23 at 1305 hours, the CDM was notified. The CDM stated [NAME] 3 should have gone to the dishwashing sink to wash the knife and whisk. 6. According to the USDA Food Code 2022, Section 5-501.110 Storing Refuse, Recyclables, and Returnables. Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. On 11/15/23 at 0810 hours, an observation and concurrent interview was conducted with the CDM. Multiple flattened cardboards boxes were observed stored between the ice machine and the food mixer. The carboard boxes were observed touching the ice machine and parts of the food mixer. The CDM verified the findings and stated the cardboard boxes were to be cut apart and moved out of the kitchen. 7. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review of the facility's P&P titled Dress Code dated 2018 under Proper Dress section showed the following: (a) hat for hair, if hair is short; (b) hair net for hair, if hair is long (over the ears or longer); (c) beards and mustaches (any facial hair) must wear beard restraint. On 11/14/23 at 1259 hours, an observation and concurrent interview was conducted with the CDM. [NAME] 1 was observed in the kitchen preparing food. [NAME] 1 was observed with a mustache and no beard covering. Additionally, [NAME] 3 was observed in the kitchen with a baseball hat worn backwards and a face mask. [NAME] 3 was observed with noticeable facial hair, not covered by the face mask, and visible hair from the opening of the baseball cap, behind his ears, and around his neck. The CDM verified these findings and stated the facility had beard coverings and they should have worn the beard and hair coverings. On 11/15/23 at 0807 hours, [NAME] 1 was observed in the kitchen. [NAME] 1's mustache was observed with no beard covering. When [NAME] 1 was asked about his beard covering, [NAME] 1 was observed putting on a face mask. On 11/17/23 at 1316 hours, an observation and concurrent interview was conducted with the CDM. An (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 25 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many outside vendor was observed walking through the main kitchen and stopped to speak to the CDM. The vendor was observed to have facial beard and hair not covered with a beard or hair covering. When asked, the CDM stated the vendor should have a beard and hair covering. 8. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility's P&P titled Sanitation dated 2018 showed the Food and Nutrition Services (FNS) Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. All equipment shall be maintained as necessary and kept in working conditions. The P&P further showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. a. On 11/14/23 at 0755 hours, during an initial tour of the kitchen, the following items were observed: - three dirty knives stored inside a steam pan with clean cooking utensils, - two steam pans holding clean cooking utensils had food particles at the bottom of the pans, - a damp brush with yellow liquid remnants stored in a bin of clean kitchen utensils, and - a can opener stored on a rack with sticky brown residue. On 11/14/23 at 0800 hours, a damp brush with yellow liquid remnants was observed inside a bin containing clean kitchen utensils. [NAME] 4 verified this finding. On 11/14/23 at 1035 hours, an interview and concurrent observation was conducted with the CDM. The CDM verified the above findings. The CDM removed the knives to be cleaned and stated the steam pans and utensils would be rewashed. b. On 11/14/23 at 0900 hours, during the initial tour of the SNF kitchen with the RD, the lowerator (an adjustable heated plate dispenser) was observed with plates and brown substance inside, at the bottom. On 11/15/23 at 0946 hours, an interview was conducted with the RD. The RD stated the kitchen staff cleaned the top surfaces of the lowerator daily, but deep cleaning of the lowerator was done monthly by maintenance. The RD verified the inside of the lowerator was not clean and stated it should be cleaner. On 11/16/23 at 1312 hours, an interview was conducted with the Maintenance Director and Maintenance Assistance. The Maintenance Director stated the lowerator was deep cleaned every six months or as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 26 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many needed when notified by the kitchen. The Maintenance Director stated the lowerator was last cleaned by the maintenance assistance on 3/15/23. The Maintenance Director stated he did not keep a cleaning log for the plate warmer. c. On 11/14/23 at 1035 hours, an observation and concurrent interview was conducted with the CDM. The Ansul fire system (automatic fire suppression system that can tackle large, hazardous fires without human intervention) was observed with black fuzzy buildup on two of six nozzles. The CDM verified the finding. The CDM stated maintenance was responsible for cleaning the Ansul fire system. On 11/15/23 at 0955 hours, an interview was conducted with the Maintenance Director. The Maintenance Director was shown a photo of the build-up on the nozzles. The Maintenance Director stated the Ansul suppression system was cleaned every six months by an outside company. On 11/15/23 at 1105 hours, a follow-up interview was conducted with the Maintenance Director. The Maintenance Director stated ABLE Duct Cleaning and FireMaster Master Protection, LP were responsible for cleaning the Ansul suppression system which included cleaning the nozzles and pipes. The Maintenance Director stated the last service by the cleaning company was 9/2023. The Maintenance Director further stated he would talk to the company regarding cleaning the pipes and nozzles. 9. Review of the facility's P&P titled Sanitation dated 2018 showed the Food and Nutrition Services (FNS) Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. All equipment shall be maintained as necessary and kept in working conditions. The P&P showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. On 11/14/23 at 1035 hours, during a subsequent tour of the kitchen, an interview and concurrent observation was conducted with the CDM. The following was observed: - three chipped rubber spatulas stored in a steam pan, - one can opener (can opener #1) in the stand, with chipped stainless-steel coating, exposing the blade, - one can opener stored on a rack (can opener #2), with chipped stainless-steel coating, exposing the blade. The CDM verified the above findings and stated the spatulas and can opener blades needed to be replaced. 10. Review of the facility P&P titled Storage of Food and Supplies dated 2017 showed bins/containers are to be labeled, covered and dated. On 11/14/23 at 1035 hours, an observation and concurrent interview was conducted with the CDM. A metal container labeled white rice was observed with no date. The CDM verified there were no dates on the bin. The CDM stated it should be labeled with a use-by date. 11.a. Review of the facility's P&P titled Procedure for Refrigerated Storage dated 2018 showed food should be covered and stored loosely to permit circulation of air. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 27 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 11/14/23 at 0755 hours, during initial kitchen tour, a tray of desserts was observed in the walk-in refrigerator. The desserts were observed not covered. On 11/14/23 at 1055 hours, an interview was conducted with the CDM. The CDM stated all foods in the walk-in refrigerator should be covered. The CDM was shown a picture of the dessert observed during the initial tour. The CDM stated it should have been covered. b. Review of the facility's P&P titled Storage of Food and Supplies dated 2017 showed food and supplies will be stored properly and in a safe manner. The Procedures for Dry Storage section showed all shelves and storage racks or platforms should in accordance with the state and federal regulations to facilitate air circulation and promote easy and regular cleaning. On 11/14/23 at 1310 hours, an observation and concurrent interview was conduct with the CDM. Multiple boxes of food were observed stacked on top of two milk crates in the dry storage room. The CDM verified it was not advisable to store food or boxes on top of milk crates because it was hard to clean underneath. On 11/17/23 at 1458 hours the Administrator, DON, Clinical Resource RN, CDM and RD were notified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 28 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document review, and facility P&P review, the facility failed to ensure the food items brought to the facility for the residents were stored or reheated for future resident consumption; and failed to ensure education was provided to staff and family/visitor regarding safe handling of the food brought into the facility. These failures had the potential to limit the residents' rights and enjoyment of food brought in by the family or visitors. Residents Affected - Few Findings: Review of the facility's P&P titled San [NAME] Hills Foods Brought by family/Visitors Policy revised 10/23 showed (6) Perishable foods will not be stored in facility. Perishable foods can be brought in by family members and checked by nursing and can be used by residents on that meal; the leftover will be discarded after two hours. On 11/16/23 at 0840 hours, an interview was conducted with LVN 1. LVN 1 stated when family or visitors brought in outside food, the staff would check the food to ensure appropriate diet. LVN 1 stated he explained the facility's policy to the residents' family members and visitors and informed them that food was not stored due to the potential for infection. On 11/16/23 at 0846 hours, an interview was conducted with the RD. The RD stated the facility did not store food for the residents. When asked what education was provided to the visitors and family members regarding the safe food handling, the RD stated the family/visitors were highly encouraged to buy food from the restaurants immediately before coming to the facility, or brought in food that was made at home that day. The RD further stated verbal instructions were given, and handouts would be provided to the family/visitor when requested. On 11/16/23 1334 hours, an interview was conducted with the DON. The DON stated on admission, the family and visitors would be informed of the facility's policy regarding food brought in. The DON stated food could be brought in for the residents to consume but would not be stored. The DON further stated the food should be consumed the same day and would be discarded after two hours. The DON verified the facility did not reheat food brought into the facility. On 11/16/23 at 1343 hours, an interview was conducted with the DSD. The DSD verified trainings and in-service provided to the staff consisted of reviewing contents on the facility's policy titled San [NAME] Hills Foods Brought by Family/Visitors Policy. The DSD verified there were no other trainings or in-service provided to the staff regarding safe handling of food brought into the facility. On 11/17/23 at 1458 hours the Administrator, DON, Clinical Resource RN, CDM, and RD were notified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 29 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were maintained in the facility's laundry room area when employee personal belongings were observed in the clean linen area. This failure posed the risk of contamination of clean linen, transmission of disease-causing microorganisms and infections. Residents Affected - Some Findings: Review of the facility's P&P titled Departmental (Environmental Services)- Laundry and Linen revised January 2014 showed the facility will provide a process for a safe and aseptic handling, washing and storage of linen. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness), through measures designed to protect it from environmental contamination, such as covering clean linen carts. On 11/16/23 at 1015 hours, an observation of the laundry area and concurrent interview was conducted with the Housekeeping Supervisor/Maintenance Director. A partially torn paper box of miscellaneous employee personal items was observed in the clean linen folding table and employee personal clothing (jacket) was observed stored in the clean linen storage rack. The Housekeeping Supervisor/Maintenance Director verified the observation and stated the employee's personal belongings should not have been stored in a clean laundry area. A housekeeping staff was observed taking out the employee belongings from the clean linen area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 30 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of four nonsampled residents (Resident 632). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria. Residents Affected - Few Findings: Review of the facility's P&P titled Antibiotic Stewardship- Order for Antibiotics dated December 2016 showed appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcome revised December 2016 showed the IP or designee, will review antibiotic utilization as a part of the antibiotic stewardship program and identify specific situation that are not consistent with the appropriate use of antibiotic. The P&P further showed at the conclusion of the review, the provider to be notified of the review findings. Medical record review for Resident 632 was initiated on 11/16/23. Resident 632 was admitted to the facility on [DATE]. Review of the Resident 632's Physician Order Summary showed physician order dated 11/3/23, to administer Levaquin (medication to treat bacterial infection) tablet 500 mg through G-tube (a tube inserted surgically through the abdomen that brings nutrition directly to the stomach) for Pneumonia (lung infection caused by bacteria, virus, or fungi) for seven days. Review of Resident 632's Medication Administration Record dated 11/1 to 11/30/23, showed Resident 632 received Levaquin 500 mg through G-tube from 11/3 to 11/9/23. Review of Resident 632's Revised Mcgeer Criteria for Infection Surveillance Checklist for Respiratory Tract Infection dated 11/3/23, showed respiratory tract infection criteria did not met for pneumonia. Review of the medical record for Residents 632 failed to show if the physician was notified of the infection that did not meet the McGeer's criteria. On 11/16/23 at 1229 hours, an interview and concurrent medical record review for Resident 632 was conducted with the IP/DSD. The IP/DSD verified the above findings. The IP/DSD was asked about the facility's antibiotic stewardship program. The IP/DSD stated the facility used McGeer's criteria. The IP/DSD stated if a resident did not meet the criteria for an infection using McGeer's criteria, the physician was notified. When asked the IP/DSD to show the documentation if the physician had been notified when the infection criteria were not met for Resident 632, the IP/DSD reviewed the medical record for Resident 632 and stated she was unable to provide the documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 31 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential equipment were maintained in safe operating condition when: Residents Affected - Few * Two ice machines were not cleaned and/or sanitized as per the manufacturer's guidelines. * The [NAME] dishwashing machine temperature was not monitored as per the dishwashing machine and facility P&P guidelines; and the temperature dial for the dishwashing machine failed to accurately measure the water temperature. These failures had the potential for equipment to not function in the way they were intended to. Findings: 1. Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2018 showed to clean inside of the ice machine with a sanitizing agent per the manufacturer's instructions. Review of the Hoshizaki America, INC Low-Profile Modular Crescent Cuber Cleaning and Sanitizing Instructions dated 8/19/13, showed for sanitizing: dilute a 5.25% sodium hypochlorite solution (chlorine bleach) with warm water . Review of the Scotsman Ice Maker-Dispenser Sanitation and Cleaning Instructions dated 11/2008 showed the following: - Mix eight ounces of Scotsman Ice Machine Scale Remover and three quarts of hot (95 degrees F-115 degrees F) potable water, and - Repeat steps 3-11, except substitute a locally approved sanitizing solution for the cleaner. A possible sanitizing solution may be obtained by mixing one ounce of household bleach with two gallons of clean, warm water. On 11/14/23 at 0935 hours, an interview was conducted with the Maintenance Director regarding cleaning and sanitizing of the ice machine. The Maintenance Director stated the ice machine was cleaned and sanitized by the maintenance assistance. The Maintenance Director also stated Hoshizaki Scaleaway was used to clean and sanitize both ice machines. On 11/14/23 at 1025 hours, an interview and concurrent document review was conducted with the maintenance assistance. The maintenance assistance verified he used the Hoshizaki Scaleaway to clean and sanitize both the Hoshizaki and Scotsman ice machines. A concurrent review of the Hoshizaki Cleaning and Sanitizing Instructions was conducted with the Maintenance Assistant. The Maintenance assistant stated he was not aware he needed to use a different chemical to sanitize the ice machine. Review of the Scotsman Ice Machine Cleaning and Sanitizing Instructions was conducted with the Maintenance Assistant. The Maintenance Assistant verified the instructions showed to use a Scotsman scale remover to clean and bleach to sanitize. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 32 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the facility's P&P titled Dishwashing dated 2018 showed all dishes will be properly sanitized through the dishwasher. The Procedure section showed (8) a temperature log will be kept and maintained by the dishwashers to assure that the dish machine is working correctly. This log will be completed each meal prior to any dishwashing; (9) the dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations. Please check your manufacturer's recommendations, which should be posted on your machine. If you cannot achieve this temperature, alert the dietetic supervisor or cook who will alert the maintenance personnel and stop washing dishes. Review of the manufacturer's recommendations, posted on the [NAME] dishwashing machine showed the following: - wash temperature: 120 degrees F minimum - rinse temperature: 120 degrees F minimum On 11/16/23 at 0905 hours, an observation and concurrent interview was conducted with the CDM. The CDM stated all pots and pans in the main kitchen went through the dish machine. The temperature dial for the dish machine showed 100 degrees F for the wash cycle, and 108 degrees F for rinse cycle. Another wash cycle was attempted. The temperature dial showed 110 degrees F. A thermometer was placed on the rack at plate level and put through the dishwasher. The temperature showed 117 degrees F. On 11/17/23 at 1312 hours, a follow-up observation and concurrent interview was conducted with the CDM. The dishwashing machine temperature dial showed 96 degrees F for wash cycle and 113 degrees F for the rinse cycle. A second wash cycle was done. DA 3 inserted the thermometer into the drain water. The thermometer showed 120.4 degrees F. The temperature dial showed 112 degrees F. The CDM stated the temperature dial is not match the temperature obtained manually. The CDM further stated he would contact the manufacturer to get the temperature dial replaced. On 11/17/23 at 1317 hours, an interview and concurrent facility document review was conducted with the CDM. The CDM reviewed the Temperature Log Dish Machine- Low Temp for 10/2023 and 11/2023. The log showed the following recorded wash temperatures: - 10/1/23-10/31/23, for breakfast, lunch, and dinner, 110 degrees F - 11/1/23-11/3/23, for breakfast and lunch, 110 degrees F - 11/4/23- 11/16/23, for breakfast, lunch, and dinner, 110 degrees F Further review of the temperature logs showed guidance that the wash cycle must be between 110 to 120 degrees F. The CDM stated the temperature guideline was incorrect. The CDM further stated the wash temperature should be at least 120 degrees F. When asked, when did he reviewed the logs, the CDM stated he reviewed the logs monthly prior to filing. When asked if the CDM noticed the discrepancy in the temperature monitoring, the CDM stated he did not look at the logs that close. On 11/17/23 at 1458 hours the Administrator, DON, Clinical Resource RN, CDM, and RD were notified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 33 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's document titled Bed Rail/ Assist Bar Safety Audit dated 4/28/23, showed all the beds in the facility were inspected. The audit report showed the Zones 1, 2, 3, 4, and 7 were checked but there were no specific measurements recorded, and did not specify whether the bed had unilateral or bilateral rails. In addition, further review of the residents' medical records and facility document showed the resident beds in the facility were not inspected for possible ent rapment when the resident had the side rails. For example: On 11/14/23 at 0901 hours, during the initial tour of the facility, an observation and interview was conducted with Resident 332. Resident 332 was observed lying in bed with a right hand assist rail elevated. Resident 332 stated he used the assist rail to turn and reposition himself. On 11/16/23 at 1400, 1411, and 1430 hours, Resident 332 was observed lying in bed with a right hand assist rail elevated. Medical record review for Resident 332 was initiated on 11/14/23. Resident 332 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 332 was cognitively intact. Review of Resident 332's Order Summary Report showed a physician's order dated 11/14/23, for the right hand assist rails for bed mobility and repositioning. Review of Resident 332's plan of care showed a care plan problem dated 11/9/23, addressing the risk for recurrent seizure episode due to seizure disorder. The interventions included to provide padded side rails as indicated. Review of Resident 332's therapy assessment report dated 11/10/23, under the Recommendations section, showed the right assist handle was recommended to assist/train bed mobility, transfers, and repositioning. Review of Resident 332's Side Rail Screening Tool v2 dated 11/14/23, showed a unilateral right assist handle was recommended to support self during care, to scoot self-up in bed to maintain proper positioning, and to change from lying to sitting position; and also showed the alternative measures prior to the use of the side rails. However, the screening report did not include an entrapment assessment. On 11/16/23 at 1347 hours, an interview and concurrent facility document review was conducted with the Maintenance Director/Housekeeping Supervisor. When asked about the bed inspection process, the Maintenance Director/Housekeeping Supervisor stated he checked if there was a gap between the mattress, foot board, headboard, and side rails. The Maintenance Director/Housekeeping Supervisor stated he used a triangular cylinder shape measuring device and made sure the measuring device did not go through the gaps in between the bed and side rails. When asked if he inspected the bed for possible areas of entrapment when the resident upon the initial installation of the assist rail, or when there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 34 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a change of bed or mattress such as a low air loss mattress or a bariatric mattress, the Maintenance Director/Housekeeping Supervisor answered no. The Maintenance Director/Housekeeping Supervisor stated the bed inspection was done annually, not when there was a change of the bed, or mattress, or user. On 11/16/23 at 1444 hours, an interview and concurrent medical record review and facility document review was conducted with the DON. The DON verified the above findings. When asked about the assist rails, the DON stated there should be a physician's order, a consent, a care plan and an assessment in order for a resident to have side rails. When asked about the assessment, the DON stated the assessment included the alternative or non-restrictive approach prior to using the side rails, and the reason why the resident used or needed the side rails. When asked about the entrapment assessment, the DON stated the entrapment assessment should be part of the side rail screening done by the nurses and the bed inspection done by the maintenance department. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all three residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety Rev. 1/2023 showed to try to prevent deaths/injuries from beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 35 of 36 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 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Inspection by maintenance staff of all beds and elated equipment as part of the regular bed program to identify risks and problems including potential entrapment risks; -Review the gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement of bed position); and -Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (examples such as altered mental status, restlessness, etc.) 1. On 11/14/23 at 0950 hours, Resident 10 was observed in bed with bilateral siderails elevated. Medical record review for Resident 10 was initiated on 11/15/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Order Summary Report for 10/11/23-11/16/23, showed an order dated 10/13/23, for bilateral assist handrails for bed mobility and positioning. Review of Resident 10's Side Rails Screening tool V.2 dated 10/18/23, showed Resident 10 would benefit from the use of bilateral handrail assist. The IDT believed the use of a bilateral assist rail would further enhance the ability to participate in the completion of ADL care (repositioning, transfers and bed mobility). However, there was no entrapment assessment completed for the use of the side rails. 2. On 11/14/23 at 0857 hours and 11/16/23 at 0907 hours, Resident 630 was observed in bed with bilateral siderails elevated. Medical record review for Resident 630 was initiated on 11/16/23. Resident 630 was admitted to the facility on [DATE]. Review of Resident 630's MDS dated [DATE] showed Resident 63 had severe cognitive impairment with BIMS score of four (zero to seven means, severe cognitive impairment). Review of Resident 630's Side Rails Screening tool V.2 dated 10/18/23, showed Resident 630 would benefit from the use of the bilateral handrail assist. The IDT believed the use of the bilateral assist rail would further enhance the ability to participate in the completion of ADL care (repositioning, transfers and bed mobility). However, there was no entrapment assessment completed for the use of the side rails. On 11/16/23 at 1350 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the bed inspection was done annually, during the month of April. The facility had the kit to check for the entrapment. Headboard was placed between the rails. When asked if entrapment assessment and bed inspection were completed if there was a change of bed or resident, the Maintenance Director verified there were no bed inspection and entrapment assessment for each resident. On 11/16/23 at 1414 hours, an interview and concurrent record review for Residents 10 and 630 was conducted with the DON. The DON verified the bed inspections were done annually and were not done when the residents had the side rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 36 of 36