San Juan Capistrano, CA

San Juan Hills Healthcare Center

4-star overall rating with 3-star inspections with $3,174 in total fines with 28 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

31741 Rancho Viejo Road, San Juan Capistrano, CA

(949) 248-8855

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Aspen Skilled Healthcare

Operator or chain grouping

Approved since

2000-08-31

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

34 facilities

Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.77

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.39

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.60

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.76

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

2.16

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

3.99

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.78

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.46

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.55

CMS adjusted RN staffing hours

Adjusted total hours

3.39

CMS adjusted total nurse staffing hours

Case-mix index

1.92

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

33%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,138

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.88

Composite VBP score used to determine payment impact.

Payment multiplier

0.9880

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.94

Baseline 21.13% · Performance 20.07% · Measure score 2.94 · Achievement 2.94 · Improvement 2.09

Healthcare-associated infections

Baseline 7.32% · Performance 8.77% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

8.50

Baseline 55.56% · Performance 28.95% · Measure score 8.50 · Achievement 8.50 · Improvement 8.17

Adjusted total nurse staffing

2.11

Baseline 4.19 hours · Performance 3.68 hours · Measure score 2.11 · Achievement 2.11 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.16%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 365 · Observed rate 8.77% · Lower 95% interval 7.84%
Discharge to community	67.42%	50.57% 16.9 pts better	Better than the National Rate · Eligible stays 393 · Observed rate 62.6% · Lower 95% interval 62.46%
Medicare spending per beneficiary	1.23	1.02 0.2 pts worse
Drug regimen review with follow-up	99.57%	95.27% 4.3 pts better	Numerator 229 · Denominator 230
Falls with major injury	0.43%	0.77% 0.3 pts better	Numerator 1 · Denominator 230
Discharge self-care score	77.27%	53.69% 23.6 pts better	Numerator 68 · Denominator 88
Discharge mobility score	59.09%	50.94% 8.2 pts better	Numerator 52 · Denominator 88
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 230 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.77%	7.12% 1.6 pts worse	No Different than the National Rate · Eligible stays 240 · Observed rate 9.17% · Lower 95% interval 6.29%
Staff COVID-19 vaccination coverage	11.36%	8.2% 3.2 pts better	Numerator 5 · Denominator 44
Staff flu vaccination coverage	64%	42% 22 pts better	Numerator 32 · Denominator 50
Discharge function score	67.05%	56.45% 10.6 pts better	Numerator 59 · Denominator 88
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 65 · Denominator 65
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 158 · Denominator 158
Resident COVID-19 vaccinations up to date	20.66%	25.2% 4.5 pts worse	Numerator 25 · Denominator 121

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.1%	94.0% 5.1 pts better	81.7% 17.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.5% · Q3 98.6% · Q4 98.2% · 4Q avg 99.1%
Percentage of short-stay residents who had an outpatient emergency department visit	10.8%	11.2% 0.4 pts better	12.0% 1.2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 9.9% · Expected 10.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.5% 0.8 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.6%	93.2% 5.4 pts better	79.7% 18.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.1%	23.2% 2.1 pts better	23.9% 2.8 pts better	Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 18.9% · Expected 21.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-15 · Fire 2024-11-15

28 health deficiencies

Top issue: Nutrition and Dietary (5 deficiencies)

9 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)

Cycle 2 Health 2023-11-17 · Fire 2023-11-17

17 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2022-10-20 · Fire 2022-10-20

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-14

F · Potential for more than minimal harm 2024-11-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-15

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-15

K928 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.

Corrected 2024-12-14

C · Minimal harm 2024-11-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-12-14

C · Minimal harm 2024-11-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-12-14

E · Potential for more than minimal harm 2023-11-17

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-12-07

E · Potential for more than minimal harm 2023-11-17

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-12-07

D · Potential for more than minimal harm 2023-11-17

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2023-12-07

D · Potential for more than minimal harm 2023-11-17

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-07

D · Potential for more than minimal harm 2023-11-17

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-12-07

C · Minimal harm 2023-11-17

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-12-07

D · Potential for more than minimal harm 2022-10-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-11-04

D · Potential for more than minimal harm 2022-10-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-04

D · Potential for more than minimal harm 2022-10-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-11-04

D · Potential for more than minimal harm 2022-10-20

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-11-04

D · Potential for more than minimal harm 2022-10-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-04

D · Potential for more than minimal harm 2022-10-20

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-11-04

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-15

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-11-12

D · Potential for more than minimal harm 2025-07-15

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-08-02

B · Minimal harm 2025-07-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-02

B · Minimal harm 2025-07-15

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-08-02

B · Minimal harm 2025-05-23

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-06-19

E · Potential for more than minimal harm 2024-11-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-15

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2024-12-13

B · Minimal harm 2024-11-15

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-12-13

B · Minimal harm 2024-11-15

F574 · Resident Rights Deficiencies

Health

The resident has the right to receive notices in a format and a language he or she understands.

Corrected 2024-12-13

B · Minimal harm 2024-11-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-13

B · Minimal harm 2024-11-15

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-12-13

G · Actual harm 2023-12-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-01-02

F · Potential for more than minimal harm 2023-11-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F758 · Pharmacy Service Deficiencies

Health

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-17

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-12-17

D · Potential for more than minimal harm 2023-11-17

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2023-12-15

B · Minimal harm 2023-11-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-15

E · Potential for more than minimal harm 2022-10-20

F761 · Pharmacy Service Deficiencies

Health

Corrected 2022-11-10

E · Potential for more than minimal harm 2022-10-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2022-11-10

D · Potential for more than minimal harm 2022-10-20

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2022-11-10

Penalties and ownership