San Juan Hills Healthcare Center
SAN JUAN HILLS HEALTHCARE CENTER in SAN JUAN CAPISTRANO, CA — inspection on May 26, 2026.
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
Review of the facility's P&P titled General Policies for IV Therapy revised on 3/2023 showed documentation of IV therapy should include but is not limited to: - Intake and ouput;- Vital signs every shift;- IV medication administration; - Response of therapy; and- IV site assessment.
Medical record review for Resident 2 was initiated on 5/22/26. Resident 2 was admitted to the facility on [DATE].
Review of Resident 2's H&P examination dated 2/18/26, showed Resident 2 had the capacity to understand and make decisions.
Review of Resident 2's Order Summary Report for May 2026 showed a discontinued physician's order dated 5/15/26, and an active physician's order dated 5/22/26, to administer sodium chloride solution 0.9%, one liter at 50 ml/hr intravenously every shift for poor oral intake.
However, review of Resident 2's medical record failed to show a COC report and 72-hour documentation monitoring were completed related to the resident's poor oral intake and IV fluid orders. On 5/2626 at 1348 hours, an interview and concurrent medical record review of Resident 2 was conducted with LVN 4. LVN 4 verified the above findings and stated the resident's new IV fluid orders would be considered a COC. LVN 4 stated there was no documented evidence of a COC or 72-hour monitoring for the COC. On 5/26/26 at 1545 hours, an interview and concurrent medical record review of Resident 2 was conducted with the DON.
The DON verified Resident 2 started on IV fluids 5/15/26, and received a new order on 5/22/26.
The DON acknowledged there was no COC or 72-hour documentation monitoring completed.
The DON stated there should have been a COC to identify the reason for IV fluids and 72-hour monitoring to ensure the interventions were effective. On 5/26/26 at 1625 hours, an interview was conducted with the Administrator and DON.
The Administrator and DON were 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555763 05/26/2026
San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675
Review of the AFL 19-16 dated 4/9/19, showed facilities must use CDPH forms 530 and 612.
The facility was responsible for ensuring all entries are accurate and legible.
Unacceptable documentation includes, but is not limited to: - Census forms (CDPH Form 612) without the original verifying signature from the Administrator, DON or DON designee.
Review of the CDPH 612 form dated 7/2019 showed to verify this form is complete, true, and accurate, the DON or designee must sign this form.
Review of the facility's document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) [CDPH 612 form] dated 5/20/26, showed no documented evidence of the Actual Direct Care Service Hours and no documented signature of the DON or assigned designee.
Review of the facility's document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) [CDPH 612 form] dated 5/22/26, showed no documented evidence of the Actual Direct Care Service Hours and no documented signature of the DON or assigned designee. On 5/22/26 at 0811 hours, an interview and concurrent facility document review was conducted with LVN 1. LVN 1 verified the DHPPD posting at the nurse's station was not current and dated 5/20/26. LVN 1 stated the Actual Direct Care Nursing Hours should be completed and the form should be signed by the DON or DON designee. On 5/22/26 at 1527 hours, an interview and concurrent facility document review was conducted with the DSD.
The DSD verified the DHPPD form dated 5/20/26, did not show the Actual Direct Care Service Hours and did not show the DON or designee's signature.
The DSD stated the DON or DSD signed the DHPPD form and it was required to be posted daily.
The DSD further stated the DHPPD form informed families or visitors the staffing levels had met the needs of the census. On 5/26/26 at 0730 hours, an interview and concurrent facility document review was conducted with LVN 3. LVN 3 verified the DHPPD form posted at the nurses' station was dated 5/22/26, and was not signed by the DON or designee. LVN 3 further verified the form did not include the Actual Direct Care Service Hours. LVN 3 stated there were no other DHPPD postings from 5/22 through 5/26/26. LVN 3 stated the DSD usually updated the forms daily. On 5/26/26 at 0752 hours, a follow interview and concurrent facility document review was conducted with the DSD.
The DSD verified the DHPPD form dated 5/22/26, did not show the Actual Direct Care Service Hours and was not signed by the DON or assigned designee.
The DSD further verified there were no DHPPD posted from 5/23 to 5/26/26.
The DSD stated the DHPPD form should be posted daily, including weekends. On 5/26/26 at 1625 hours, an interview was conducted with the Administrator and DON.
The Administrator and DON were informed and acknowledged the above findings.
555763 05/26/2026
San Juan Hills Healthcare Center 31741 Rancho Viejo Road San Juan Capistrano, CA 92675
injection medication. LVN 1 stated there should be a physician's order and the medications should be
bedside and must observe self-administration when permitted. On 5/22/25 at 1019 hours, an
medications at 0630 hours and acknowledged she left the Tylenol (pain medication) and famotidine (acid reflux medication) at the bedside. LVN 2 stated medications should not be left unattended to prevent inaccurate dosing and to ensure other residents or visitors do not access them. On 5/26/26 at 1545 hours, an interview and concurrent medical record review of Resident 1 was conducted with the DON.
The DON acknowledged the above findings and stated medications should not be kept unattended at bedside and must be stored in the medication carts.
The DON stated medications approved for self-administration could be stored inside the resident's bedside drawer.
The DON verified Resident 1 had a self-administration assessment completed by the licensed nurse who received the order for the self-administration; however, the DON stated the facility did not conduct an IDT assessment to determine Resident 1's ability to self-administer her medications and conduct a skilled assessment per the facility's P&P. On 5/26/26 at 1625 hours, an interview with was conducted with the Administrator and DON.
The Administrator and DON were informed and acknowledged the above findings.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.