Health inspection·May 23, 2025

F 0842 a. The date and time the procedure/treatment was provided; Level of Harm - Potential for minimal harm b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; Residents Affected - Some d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Review of the facility P&P titled Nursing Care of the Resident with Diabetes Mellitus revised 12/2015 showed approximate reference ranges for hypoglycemia are: mild hypoglycemia 55-70 mg/dL; moderate hypoglycemia 40-55 mg/dL; and severe hypoglycemia < 40 mg/dL. Closed medical record review for Resident 1 was initiated on 5/15/25. Resident 1 was admitted to the facility on [DATE], and discharged to the acute care hospital on 6/17/24. a. Review of Resident 1's Care Plan Report dated 5/31/24 showed the resident was at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes (high blood sugar). Review of Resident 1's Progress Notes showed a late entry note dated 6/7/24, showed in the morning, Resident 1 had a blood sugar level of 58 mg/dL. Resident was alert, oriented, answering the questions appropriately and stating he felt fine. Resident 1 did not have any signs or symptoms of low blood sugars. The vital signs were within normal limits. Resident 1 was given a glass of orange juice with two packets of sugar. The resident's blood sugar was rechecked with a reading of 94 mg/dL. Review of Resident 1's Weights and Vital Summary dated 6/7/24, did not show Resident 1's blood sugar reading of 58 mg/dL. Review of Resident 1's Medication Administration Record for June 2024 did not show Resident 1's blood sugar reading of 58 mg/dL. Review of Resident 1's eINTERACT Version 5.0 did not show Resident 1 had a COC for low blood sugar level of 58 mg/dL. On 5/23/25 at 1028 hours, and interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 stated the process for a COC would be to open the eINTERACT COC form, which included notifying the physician and resident's representative. When asked what the parameters for hypoglycemia would be, LVN 1 stated for the blood sugar levels below 70 mg/dL. When asked if the blood sugar levelof 58 mg/dL would require a COC, LVN 1 stated yes definitely, they should have done a COC. When asked if there was a COC for Resident 1's blood sugar level of 58 mg/dL, LVN 1 stated unfortunately no, not even a daily skilled note. LVN 1 verified the findings. On 5/23/25 at 1500 hours, an interview and concurrent closedmedical record review was conducted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 2 of 3 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 05/23/2025 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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some with the DON. The DON stated a blood sugar level below 70 mg/dL would indicate hypoglycemia. The DON stated the process of a COC was to assess the resident, notify the physician and resident's representative, and monitor the resident after the COC. When asked if a blood sugar level of 58 mg/dL would require a COC, the DON stated it should andthat was why they notified the physician. When asked if there was a COC, the DON stated no, but the nurse made a progress note about it. When asked if the resident's representative was notified, the DON was not able to show the resident's representative was notified. The DON verified the above findings. b. Review of Resident 1's SBAR Communication Form dated 6/17/24, showed Resident 1 had a COC for altered level of consciousness, labored breathing, abnormal lung sounds, pulse oximeter (measurement of the saturation of oxygen in the blood) of 88%, blood pressure of 88/58 mmHg (millimeters of mercury), and a heart rate of 38 beats per minute. Review of Resident 1's Progress Notes dated 6/17/24 at 1247 hours, showed Resident 1 was transferred to the acute care hospital. Resident 1 was transferred out at 1247 hours. Further review of the progress notes showed the SBAR with the vital signs taken at the following dates and times: - dated 6/17/24 at 1458 hours, blood pressure 85/58 mmHg; - dated 6//17/24 at 1459 hours, pulse rate 38 beats per minute; - dated 6/16/24 at 0624 hours, respiratory rate 17; and -dated 6//17/24 at 1500 hours, pulse oximetry 88%. On 5/23/25 at 1028 hours an interview was conducted with LVN 1. LVN 1 stated when a COC was initiated, a current set of the vital signs would be taken. On 5/23/25 at 1500 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified the vital signs above were documented as taken after the resident had already been discharged from the facility. The DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 3 of 3