Inspection·July 15, 2025

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 the care plan was revised to reflected the individual care needs for one of four sampled residents (Resident 1). * The facility failed to develop a different interventions in Resident 1's care plan to prevent constipation. This failure posed the risk of not providing the appropriate, consistent, and resident-centered care to the resident. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan: when there has been a significant change in the resident's condition and when the desired outcome is not met. Closed medical review for Resident 1 was initiated on 7/15/25. Resident 1 was admitted to the facility on [DATE], and discharged on 6/6/25. Review of Resident 1's Progress Note showed the following notes:- dated 6/4/25, Resident 1 had no BM for three days, and complained of abdominal distention as well as nausea and vomiting.- dated 6/5/25, Resident 1 had no BM, the milk of magnesia (laxative) was ineffective. The MD was made aware and ordered to give fleet enema (type of saline used to relieve constipation) right away.- dated 6/5/25, Resident 1 still had an episode of nausea/vomiting. Resident had no BM for six days, administered the fleet enema and a small amount of stool noted after the administration .of the fleet enema Resident 1 still had abdominal distention and feeling nauseous.- dated 6/6/25, Resident 1was transferred to the acute care hospital. The indication for the acute care hospital transfer was due to abdominal distention, no bowel movement for more than three days and persistent nausea and vomiting. Review of Resident 1's Transfer Form dated 6/6/25, showed Resident 1 was transferred to the acute care hospital due to constipation. Review of Resident 1's care plan initiated on 5/28/25, showed a care plan problem addressing Resident 1's risk for constipation related to decreased mobility and possible adverse reaction to the medication. The interventions included to monitor/record BM (bowel movement) every shift and report hard, dry, bloody stool, and if no BM more than three days, check for constipation, abdominal distention and notify MD as needed and give the medication as ordered, monitor/report effectiveness versus the side effects. Further review of Resident 1's closed medical record failed to show for an additional or different interventions in the care plan problem and interventions when Resident 1 had no bowel movement for more than three days. On 7/15/25 at 1350 hours, an interview and concurrent closed medical review was conducted with LVN 1. LVN 1 verified the care plan for constipation was not updated. On 7/15/25 at 1500 hours, an interview and concurrent closed medical review was conducted with the DON. The DON verified and acknowledged the above findings. Cross reference to F656 and F690. Event ID: Facility ID: 555763 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 provide the necessary care and services for one of four sampled residents (Resident 1). * The facility failed to properly assess Resident 1's bowel function and provided the timely interventions as ordered by the physician when Resident 1 had no bowel movement. This failure posed a risk for the resident not to receive the necessary care and interventions to maintain the resident's normal bowel function.Findings: Review of the facility's P&P titled Bowel and Bladder Program revised 6/2021 showed it is the policy of this facility that the bowel and bladder assessment of the resident will be performed to attain and maintain the highest bowel and bladder function. Closed medical review for Resident 1 was initiated on 7/15/25. Resident 1 was admitted to the facility on [DATE], and discharged on 6/6/25. Review of Resident 1's Care Plan Report showed a care plan problem initiated on 5/28/25, addressing Resident 1's risk for constipation related to the resident's decreased mobility and possible adverse reaction to medication(s). The interventions included to monitor/record the BM (bowel movement) every shift and report hard, dry, bloody stool, if no BM for more than three days, check for constipation, abdominal distension and notify the MD as needed, offer prune juice, and give medication as ordered, monitor effectiveness versus the side effects. Review of Resident 1's Order Summary Report showed the following physician's orders for the bowel management medications dated 5/27/25:- sennosides (Senna - a laxative) tablet 8.6 mg, two tablets by mouth at bedtime for bowel management hold for loose stool, - Milk of Magnesia suspension (laxative) 1200 mg/15 ml, give 30 ml by mouth every 24 hours as needed for bowel management,- Dulcolax rectal suppository (medication inserted into a body cavity such as rectum) 10mg every 24 hours as needed for bowel management if milk of magnesia was ineffective and- Fleet Enema (type of saline used to relieve constipation) 7-19 gm/118 ml, insert rectally as needed for bowel management if Dulcolax is ineffective. Additionally, Resident 1 had a physician's order dated 6/3/25, to administer polyethylene glycol powder (laxative) 17 gram by mouth one time a day for bowel management. Review of Resident 1's Progress Note showed the notes on the following dates and times :- dated 6/4/25 at 1455 hours, Resident 1 had no BM for three days, and complained of abdominal distention as well as nausea and vomiting.- dated 6/5/25 at 1212 hours, Resident 1 had no BM, the milk of magnesia (laxative) was ineffective. The MD was made aware and had ordered to give the fleet enema (type of saline used to relieve constipation) right away.- dated 6/5/25 at 1436 hours, Resident 1 still had an episode of nausea/vomiting. Resident had no BM for six days, administered the fleet enema and a small amount of stool noted after the administration of the fleet enema. Resident 1 still had abdominal distention and feeling nauseous. - dated 6/6/25 at 1141 hours, Resident 1was transferred to an acute hospital. The indication for transfer was abdominal distention, no bowel movement for more than 3 days and persistent nausea and vomiting.- dated 6/7/25 at 0507 hours, showed the facility called the acute care hospital for follow-up and found out Resident 1 was admitted due to small bowel obstruction. Further review of Resident 1's medical records showed Resident 1 had no BM from 5/30 to 6/6/25 in the CNA's Bowel Monitoring Log. Review of Resident 1's MAR for May 2025 showed Resident 1 was administered Senna oral tablet medications, two tablets at bedtime from 5/27 to 5/31/25. Review of Resident 1's MAR for June 2025 showed the bowel management medications administered to Resident 1 on the following dates: - dated 6/1/25, Senna oral tablet two tablets at bedtime;- dated 6/2/25, Senna oral tablet two tablets at bedtime;- dated 6/3/25, Senna oral tablet two tablets at bedtime;- dated 6/4/25, Senna oral tablet two tablets at bedtime, polyethylene glycol powder 17 gram one time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555763 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555763 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a day, and Milk of Magnesia suspension 30 ml as needed for bowel management;- dated 6/5/25, Senna oral tablet two tablets at bedtime, polyethylene glycol powder 17 gram one time a day, and Fleet Enema 7-19 gm/118 ml as needed for bowel management if Dulcolax is ineffective; and - dated 6/6/25, Polyethylene glycol powder 17 gram one time a day. On 7/15/25 at 1350 hours, a concurrent interview and closed medical review was conducted with LVN 1. LVN 1 stated they check the CNA's BM Log Monitoring daily. A resident will be administered Milk of Magnesia medication, if the resident had no BM for three days. On 7/15/25 at 1500 hours, a concurrent interview and closed medical record review was conducted with the DON. The DON stated the CNAs did the daily bowel movement monitoring. The nurses checked the task daily to see if the resident had a BM or not. The DON verified Resident 1 had no BM from 5/30/25 and the as needed bowel management medications were not provided as ordered by the physician until 6/4/25, six days later. Event ID: Facility ID: 555763 If continuation sheet Page 4 of 4