Hillcrest Manor Sanitarium

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the building was secured to prevent the elopement (leaving the facility without permission) of one resident (Resident 1).As a result, Resident 1 eloped from the facility and was at risk for physical injury and psychosocial harm.Findings:A Facility Reported Incident (FRI) was received by the California Department of Public Health on 9/9/25. The FRI reported that Resident 1 was missing from the facility.Resident 1 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a long-term mental disorder), per the admission Face Sheet.A telephone interview with the Administrator (Admin) was conducted on 9/11/25 at 5:15 P.M. Per the Admin, Resident 1 had eloped from the facility in the early morning of 9/9/25. The Admin stated a window screen was found to be loose in a room leading to an outdoor storage area, and a light outline of a shoe print was observed by staff on 9/9/25 following the incident. The Admin stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for twelve days from April 1 - June 30, 2024. This failure had the potential to prevent residents from receiving the care they needed. Findings: Review of PBJ (Payroll-Based Journal) Staffing Data Report, CASPER Report 1705 (a report that can help Skilled Nursing Facilities identify areas for improvement in care and operations) for Quarter 3 2024 (April 1 - June 30) indicated that No RN hours was triggered for twelve days. On 11/20/24 at 9:30 A.M., an observation of current staffing was observed posted at nurse's station. Staffing was within normal limits. On 11/20/24 at 9:57 A.M., a concurrent interview with the Director of Nursing (DON) and record review of PBJ Staffing Data Report, CASPER Report 1705 for Quarter 3 2024 (April 1 - June 30) was conducted during the Sufficient and Competent Staffing Facility Task. The DON indicated from her records the following days did not have a RN scheduled for at 8 least hours: 4/11/24, 4/16/24, 4/18/2, 04/22/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the staff followed policy and procedure for one of 14 sampled residents (Resident 22) when: 1) the staff did not document the medication administration accurately and 2) the staff did not document the medication administration in a timely manner. As a result, there was a potential the residents did not receive the prescribed amount of medication. Findings: Resident 22 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a type of mental health illness) per the facility's admission Face Sheet. 1) A review of records was conducted. The physician order dated, 6/20/24 indicated, Resident 22 was to receive eight units of insulin (a medication to control blood sugar) three times a day. The MAR indicated, LN 2 and LN 3 gave Resident 22 six units of insulin on 11/16/24, 11/17/24 and 11/18/24. On 11/20/24 at 10:09 A.M., an interview with the DON was conducted. The DON stated LN 2 informed her that LN 2 knew the physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview the facility failed to ensure that the facility's water system was tested for Legionella (an infectious bacteria that flourishes in air conditioning and water systems that causes a flu like symptoms). This failure had the potential for residents to become infected with Legionella via contaminated water sources. Findings: On 11/21/24 at 10 A.M., during the Infection Control task, an interview with the Director of Nursing (DON) was conducted. The DON stated that she was unaware if the facility was testing the facility's water for Legionella, but that the Administrator (ADM) would know. The DON stated that it was important to test for Legionella to prevent resident infection from Legionella. On 11/21/24 at 10:46 A.M., an interview with the Maintenance Supervisor (MS) was conducted. The MS stated he did not test the water for Legionella or any other bacteria. The MS stated he only tested the water temperature. The MS stated that he was not sure if the ADM was having a company come to test the water. The MS stated that it was important to test the water to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to implement an emergency plan for food preparation when the kitchen ceiling had water damage. This failure had the potential for contamination of food for 57 residents. Findings: On 1/23/24, at 6:15 P.M., a concurrent observation was conducted with a Dietary Aide (DA 1) of the dining area. Several residents were in the dining room, some leaving the area. DA 1 stated the residents had just finished eating dinner. DA 1 stated the food preparation was done in the kitchen, but there was no leaking while the food was being prepared. On 1/23/24 at 6:25 P.M., the facility kitchen was toured with the Facility Owner (FO). Several areas of water damage were noted on the kitchen ceiling, including over the stove. Two holes were observed in the ceiling, one over dumbwater area, and one on far left side of the kitchen hood. Some areas noted to have small black circles about the size of a quarter. Pictures were taken. On 1/23/24, at 7:56 P.M., the Dietary Supervisor (DS) was interviewed. DS stated the kitchen had been used to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide a registered nurse (RN) on duty, 8 consecutive hours per day, seven days per week for 33 days out of 91 days from April 2023 thru June 2023. This failure had the potential for more advanced care activities provided by an RN to be unavailable to the residents. Findings: During the initial tour of the facility on 10/09/2023 at 9 A.M., the only RN at the facility was the Director of Nursing (DON). A review of the facility's PBJ (payroll based journal) Staffing Data Report, CASPER report 1705D, FY (fiscal year) Quarter 3, indicated, .triggered: four or more days within the quarter with no RN hours . Further review of the facility's staffing data report indicated: .Infraction dates: 04/01 (SA); 04/02 (SU); 04/08 (SA); 04/09 (SU); 04/13 (TH); 04/15 (SA); 04/16 (SU); 04/22 (SA); 04/23 (SU); 04/25 (TU); 04/28 (FR); 04/29 (SA); 05/02 (TU); 05/06 (SA); 05/07 (SU); 05/12 (FR); 05/13 (SA); 05/20 (SA); 05/21 (SU); 05/22 (MO); 05/27 (SA); 05/28 (SU); 05/29 (MO); 06/03 (SA); 06/04 (SU); 06/08 (TH); 06/10 (SA); 06/11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. Kitchen staff did not know how to calibrate food thermometers. 2. Kitchen staff did not know the quaternary ammonium concentration of the kitchen sanitizer buckets. 3. A kitchen dishwasher did not know how to correctly test PPM (parts per million) concentration of the dishwashing solution with the chlorine test strip. These failures had the potential to expose 59 residents who consumed food from the kitchen, to acquire a foodborne illness. Findings: 1. On 10/10/23 at 1:44 P.M., an observation and interview with the [NAME] 6 (CK 6) was conducted. The CK 6 stated the thermometer calibration was done every Saturday and Monday in the morning by the cook. CK 6 proceeded to place two (2) thermometers into a plastic cup with ice and no water; one thermometer read 32 degrees Fahrenheit (F) and the other thermometer read 88 F. degrees. CK 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to clarify a POLST (Physicians Order for Life Sustaining Treatment), for one of three residents (Resident 5), reviewed for Resident Rights. As a result, in the event of a cardiac arrest, staff had the potential to be confused with the current documentation and might not honor the resident's wishes. Findings: Resident 5 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a severe mental health condition which involves delusions and hallucinations), per the facility's admission Face Sheet. On 10/9/23, Resident 5's clinical record was reviewed. Taped on the outside of the paper chart were the letters DNR (Do not resuscitate). The physician orders dated 6/7/12, indicated the resident was a DNR. The pink POLST form, dated 8/22/22, listed the resident as a Full Code signed by the physician (8/22/22) and listed the conservator's office as the responsible party (RP). An interview was conducted with CNA 1 on 10/10/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain clean shower curtains for two of six resident bathrooms (Annex's male and female restrooms), reviewed for Resident Rights and Homelike Environment. As a result, there was the potential for residents to feel less valued and to have a low self-esteem. Findings: During initial tour of the Annex building on 10/9/23 at 9:10 A.M., the men's and women's bathrooms were inspected for cleanliness. The two separate bathrooms contained a shower and two commodes. Three plastic shower curtains were present, one for the shower area and one each for toiletry area for privacy. The men's three interior plastic curtains were observed with black mold-like matter and areas with smeared brown substances. The two women's interior plastic commode privacy curtains had smears of dried brown, tan, and yellow substances. An observation and interview was conducted with CNA 2 on 10/10/23 at 10:11 A.M., of the two Annex bathrooms. CNA 2 inspected the interior plastic curtains in both the men's and women's bathrooms. CNA 1 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an unplanned discharge to CMS (Centers for Medicare and Medicaid Services) for one of one resident (Resident 43), via the significant change of condition Minimum Data Set (MDS), reviewed for Resident Assessment. As a result, CMS was unaware Resident 43 had been admitted to the hospital on [DATE], and had not returned to the facility. Findings: Resident 43 was admitted to the facility on [DATE], with diagnoses which included alcohol abuse with alcohol-induced mood disorder (depressive disorder), per the facility's admission Face Sheet. An interview and record review was conducted with the MDSN on 10/10/23 at 2:58 P.M. The MDSN stated Resident 43's last MDS report sent to CMS was a quarterly report on 4/28/23. The MDSN stated Resident 43 was discharged to the hospital on 7/3/23, due to shortness of breath. The MDSN stated Resident 43's return was expected, however he never returned. The MDSN stated a Discharge MDS report was never completed or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess and report a fall, with a 6-month look back period to CMS (Centers for Medicare and Medicaid Services) via a quarterly MDS (Minimum Data Set), for one of one resident (Resident 16), reviewed for Falls. As a result, CMS was not informed of Resident 16's current medical status. Findings: Resident 16 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (a mental condition causing severe mood swings), per the facility's admission Face Sheet. An observation and interview was conducted with Resident 16 during initial tour on 10/09/23 at 8:55 A.M. Resident 16 was lying in bed and stated she fell down some stairs a few weeks ago and injured her foot. Resident 16's clinical record was reviewed on 10/10/23. According to the nurses note, dated 6/20/2023, Resident 16 fell after missing some steps and complained of pain in her right ankle. A fall care plan was initiated for the fall on 6/20/23, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a person-centered care plan related to the use of a shoe lift for one of three residents (Resident 19 ), reviewed for Limited Range of Motion (ROM). As a result, there was the potential for Resident 19 to be at risk for impaired mobility and for the staff to not consistently assess Resident 19 for risks associated with impaired mobility. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (type of memory loss), traumatic brain injury, history of traumatic fracture, per the facility's admission Face Sheet. On 10/09/23 at 9:55 A.M., an observation was conducted with Resident 19. Resident 19 was observed wearing a shoe lift on his right foot. On 10/11/23 Resident 19's clinical record was reviewed. Per the physician order dated 2/7/22, the order indicated .refer to [name] orthotic/prosthetic clinic for shoe lift [right] foot, [right] leg [is less than left leg status post history] of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a residents' low air loss (LAL-a mattress that alternates pressure points) mattress was set appropriately, and resident repositioned and documented for 1 of 1 resident (Resident 26) reviewed for Services/Treatment to Prevent Pressure Ulcers. This failure had the potential for Resident 26 to develop pressure ulcers. Findings: Resident 26 was admitted to the facility on [DATE], with diagnosis which included Schizophrenia (a mental condition affecting the mind) and Parkinson's Disease (a progressive disease affecting the nervous system), per the facility's admission Face Sheet. On 10/9/23 at 11:52 A.M., and at 2:02 P.M., an observation of Resident 26 was conducted. Resident 26 was in bed laying with the head of the bed at 15 degrees. A special mattress (LAL) was observed on Resident 26's bed with the following settings noted: 400 lbs (pounds) static at normal pressure. On 10/10/23 at 7:53 A.M., and at 10:14 A.M., an observation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure antipsychotic (major tranquilizer used when the resident may harm himself or others) PRN (as needed) medications were limited to the 14 day use, for one of five residents (54), reviewed for unnecessary use of a psychotropic medication. As a result, Resident 54 had the potential to be exposed to unnecessary side effects and harm of the medications. Findings: 1. Resident 54 was admitted to the facility on [DATE], with a diagnoses to include schizoaffective disorder (a mental illness with impaired thoughts and mood swings) and obsessive-compulsive disorder (a mental illness with unwanted thoughts and fears), per the facility's admission Face Sheet On 10/11/23, Resident 54's records were reviewed. Per the physician's orders, dated 10/08/21, Thorazine (treats mood swings) 50 mg by mouth every 12 hours as needed for severe agitation. Per the physician's orders, dated 11/04/21, Haldol (treats mood disorder) 10 mg by mouth every 8 hours as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.45%. Two medication errors were observed out of 31 opportunities, during the medication administration process for two of four randomly observed residents (Resident 19, 52). As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 10/10/23 at 8:38 A.M., an observation of medications administration was conducted with LN 11. LN 11 prepared and administered seven medications to Resident 52. One of the seven medications was Advair diskus (breathing treatment in disk-shaped) which was at counter 42, prior to administration. On 10/10/23 a medication reconciliation for Resident 52 was conducted. Per the physician order, dated 4/22/21 listed Advair diskus 50/100 one puff inhaler two times a day. On 10/10/23 at 9:55 A.M., an observation and interview was conducted with LN 11. LN 11 administered medications to Resident 52, including a dose of Advair diskus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to: 1. Secure one of two medications carts (North cart), reviewed for Medication Storage, and 2. To consistently monitor one of one medication room (north nurses station) for temperature control. As a result, there was the potential for residents and staff to have access to unauthorized medications, and there was a potential for medications were stored to ensure their integrity. Findings: 1. An observation was conducted of the charting room on 10/10/23 at 2:01 P.M. The charting door was propped wide open and unlocked. Inside the charting room was a red medication cart labeled North. The medication cart was unlocked, and no staff were nearby. The top left drawer of the medication cart contained packaged syringes and needles. On the right side of the medication cart, the second drawer down was packaged medications, which had resident names on them. Staff and one resident were observed walking past the unlocked charting room on 10/10/23 at 2:03 P.M. A male resident was observed past the opened charting room and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper food storage was met, when expired food was found in one of three refrigerators (Refrigerator 2), during initial Kitchen Tour. This failure has the potential to result in harmful bacteria growth and cross contamination, which could lead to foodborne illnesses to residents within the facility. Findings: On 10/9/23 at 8:23 A.M., a concurrent observation and interview was conducted with the [NAME] 7 (CK 7) of the kitchen refrigerator. On a shelf of the refrigerator were four plastic bags containing heads of romaine lettuce. One lettuce bag was opened on a bottom corner with one head of lettuce missing. The lettuce bag was open to the air and was labeled with a black marker, opened date of 10/6 and BB (Best By) 10/8. CK 7 stated he did not know what, BB meant. CK 7 stated the opened lettuce bag was not good and could be contaminated, so it needed to be thrown away. CK 7 further stated the opened bag of lettuce should not be used because the bag had not been secured and sealed. On 10/09/23 at 10:11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.