Health inspection·October 15, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 notify the physician when the resident had a change in condition for one of three sampled residents (Resident 1). * The facility failed to notify the physician when Resident 1 had low blood pressure readings. This had the potential for a delay in the physician prescribing necessary treatments and interventions for the resident.Findings: Review of the facility's P&P titled Administering Medications revised 12/2012 showed if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician of the facility's Medical Director to discuss the concerns. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 5/2017 showed our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Medical record review for Resident 1 was initiated on 10/15/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/31/24, showed Resident 1 had a capacity. Review of Resident 1's MAR for June 2024 showed a physician's order dated 5/31/24, for Benazepril HCL (medication to lower high blood pressure) oral tablet 10 mg, give one tablet by mouth one time a day for high blood pressure, to hold if the SBP is less than 110 mmHg. The MAR showed the following dates and blood pressure readings: - dated 6/3/24, 100/60 mmHg;- dated 6/4/24, 106/62 mmHg;- dated 6/6/24, 104/63 mmHg;- dated 6/7/24, 102/60 mmHg;- dated 6/8/24, 104/60 mmHg;- dated 6/9/24, 107/64 mmHg;- dated 6/10/24, 109/68 mmHg;- dated 6/12/24, 100/57 mmHg;- dated 6/13/24, 105/56 mmHg;- dated 6/14/24, 108/56 mmHg; and- dated 6/15/24, 100/60 mmHg. Review of Resident 1's Physical Therapy Treatment Encounter Note dated 6/15/24 at 0724 hours, showed Resident 1's blood pressure was obtained on lying, sitting, and standing positions. Resident 1's blood pressure readings were as follows:- supine position and the BP was 91/62 mmHg;- sitting position and the BP was 83/57 mmHg; and- standing position and the BP was 106/64 mmHg. Further review of Resident 1's medical record failed to show a change of condition was initiated when Resident 1's blood pressures were low. In addition, there was no documented evidence to show if Resident 1's physician was made aware. On 10/15/25 at 1333 hours, an interview and concurrent record review were conducted with PT 1. PT 1 verified the PT note dated 6/15/24, showed Resident 1 had low blood pressure readings. PT 1 acknowledged Resident 1's physician should have been made aware of Resident 1's low blood pressures readings. On 10/15/25 at 1411 hours, an interview and concurrent record review was conducted with the DON. The DON reviewed Resident 1's MAR for June 2024 and verified Resident 1 had multiple systolic blood pressures below 110 mmHg. The DON reviewed the PT note dated 6/15/25, and verified Resident 1's low blood pressures readings. The DON stated that Page 1 of 2 555763 555763 10/15/2025 San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675

F 0580 Level of Harm - Minimal harm or potential for actual harm when the blood pressure medication was held consecutively for three days in a row, the physician needed to be notified. The DON verified there was no documentation to show the change of condition and physician notification when Resident 1 had abnormal blood pressures. Residents Affected - Few 555763 Page 2 of 2