Trabuco Hills Post Acute
TRABUCO HILLS POST ACUTE in LAKE FOREST, CA — inspection on August 21, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to notify Resident 1's representative when Resident 1 had poor PO (by mouth, oral) intake (refusing meals/fluids), increased weakness, and confusion, and was sleepy on 8/3/25.
This failure had the potential to delay of notification of the resident's changes of condition to the resident's responsible party.Findings:
Review of the facility's P&P titled Notification of Changes reviewed/revised 12/19/22, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring a notification.
Under the Additional considerations section for competent individuals, showed when a resident is mentally competent, such a designated family member must be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.
Closed medical record review for Resident 1 was initiated on 8/19/25. Resident 1 was admitted to the facility on [DATE], and discharged on 8/16/25.
Review of Resident 1's H&P examination dated 12/7/24, showed the resident had the capacity to make medical decisions.
Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 8/3/2025, showed the resident had poor PO intake, was refusing meals/fluids, sleepy, and had increased weakness. In addition, the mental status evaluation showed Resident 1 had increased confusion.
However, further medical record review for Resident 1 failed to show documented evidence Resident 1's family member and/or resident representative was notified of the resident's changes in condition. On 8/21/25 at 1151 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 verified Resident 1's family member and/or resident representative was not notified of the resident's changes in condition. LVN 2 stated after the resident's change in condition was initiated, the resident's physician and family member should be notified. On 8/21/25 at 1645 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Trabuco Hills Post Acute
25652 Old Trabuco Road Lake Forest, CA 92630
SUMMARY STATEMENT OF DEFICIENCIES
physician. LVN 2 stated the licensed nurse should have called the laboratory right away and reported the abnormal laboratory results to Resident 1's physician. On 8/21/25 at 1353 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified there was no documentation to show Resident 1's physician was informed promptly regarding the resident's abnormal CBC results. RN 1 verified the above findings. RN 1 stated the licensed nurse should have called Resident 1's physician right away and document the notification. On 8/21/25 at 1645 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Trabuco Hills Post Acute
25652 Old Trabuco Road Lake Forest, CA 92630
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident 1's H&P examination dated 12/7/24, showed the resident had the capacity to make medical decisions.
Review of Resident 1's Order Summary Report dated 8/21/25, showed a physician's order dated 8/3/25 at 1830 hours, for stat CBC, BMP, and UA with C&S.
Review of Resident 1's Lab Results Report dated 8/4/25, showed the CBC collection date and time was on 8/4/25 at 1145 hours.
Review of Resident 1's Lab Results Report dated 8/5/25, showed the urinalysis collection date and time was on 8/4/25 at 0500 hours.
Review of Resident 1's Lab Results Report dated 8/5/25, showed the BMP collection date and time was on 8/4/25 at 1145 hours.
However, further closed medical record review for Resident 1 failed to show documented evidence the stat CBC, urinalysis, and BMP were collected in a timely manner. On 8/21/25 at 1203 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated the licensed nurse should have collected the urine right away or as soon as possible. LVN 2 stated the licensed nurse should have called the laboratory right away because the physician's order for Resident 1's laboratory tests were ordered as a stat order. On 8/21/25 at 1353 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 acknowledged there was no documentation the laboratory was called right away to draw/collect the resident's ordered stat laboratory tests. RN 1 stated the licensed nurse should have endorsed to the next shift if the laboratory was called and to follow up to the laboratory staff. On 8/21/25 at 1645 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
Facility ID: