HILLCREST MANOR SANITARIUM
For profit - Corporation
98 Beds
Independent
Data: November 2025
Trust Grade
60/100
#599 of 1155 in CA
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hillcrest Manor Sanitarium has a Trust Grade of C+, indicating it is slightly above average but not without concerns. It ranks #599 out of 1155 facilities in California, placing it in the bottom half, and #62 out of 81 in San Diego County, meaning only one local facility is rated higher. The facility shows an improving trend, with issues decreasing from 6 in 2024 to just 1 in 2025. Staffing is a significant weakness, with a low rating of 1 out of 5 stars and less RN coverage than 99% of California facilities, which may affect the quality of care. However, the lack of fines is a positive aspect, and there have been no critical incidents. Specific concerns included failure to implement an emergency food preparation plan during kitchen water damage, potential gaps in RN staffing for 12 days, and issues with accurate medication administration for at least one resident. While there are serious areas to address, the facility is making strides to improve overall care.
- Trust Score
- C+
- In California
- #599/1155
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Bottom 49%
No red flags
6 → 1 violations
★★★☆☆
3.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
The Ugly 27 deficiencies on record
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**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 elopeme...
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**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 window screen was loose on the right side, allowing space for a person to push open the window, and exit the room. Per the Admin, it was possible Resident 1 had eloped out the loose screen, then was able to climb over the exterior fence. The Admin stated the old, discarded equipment in the outdoor storage area may have been used as a way to climb over the fence and should not be stored in an area visible or accessible to residents.A record review was conducted on 9/15/25.Resident 1's Brief Interview for Mental Status (BIMS, an assessment of cognitive function) score was 0, indicating severely impaired cognition.Resident 1's elopement risk score dated 6/16/25 was 12, indicating he was not at risk for elopement.A concurrent interview with the Director of Maintenance (DM) and observation of the facility was conducted on 9/15/25 at 3 P.M. Window screens located in resident rooms throughout the facility, including the area where Resident 1 had resided, were loosely connected to the window frames, allowing space to reach in and pull screen forward. The DM stated he needed to replace the screens with a more secure option which could be firmly attached to the window frame.The storage area outside of the resident room involved had many large, discarded objects, including bed frames, wheelchairs, desks and office chairs, and large unidentified pieces of laundry or kitchen equipment. The discarded objects were stored against the perimeter chain link fencing. The DM stated the equipment should have been discarded as it was possible for a resident to use the equipment to climb over the six-foot fence. The DM stated he conducted weekly rounds of the facility looking for window screens or other exterior areas that needed repairs or replacement, but he had no documented evidence of the rounds.Per an undated facility policy, titled Interior General Maintenance, It is the policy of this facility to maintain in good repair at all times, all interior surfaces, fixtures.equipment.and furnishings to provide a safe, clean, comfortable environment for our patients.Per an undated facility policy, titled Elopement and Management of Missing Residents, Policy: It is the policy of the facility to promote resident safety.The facility maintains a process to assess all residents for risk of elopement.Elopement is the ability of a cognitively impaired resident, who is not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, which may cause a potential harm.
Nov 2024
5 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
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 ...
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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, 5/2/24, 5/8/24 5/16/24, 5/21/24, 5/23/24, 5/27/24, 5/28/24, 5/30/24 & 6/18/24.
The DON stated that staffing numbers for Licensed Nurses (LN) and Certified Nursing Assistants (CNAs) were within limit those days, but they were unable to retain the services of an RN. The DON stated the facility had no waivers for staffing. The DON stated that when they do not have a RN on schedule, they have tried to accommodate with more LVNs. The DON stated the expectation was the facility should have a RN at least 8 hours a day. The DON stated the importance of having a RN at least 8 hours a day was to oversee patient care and safety, supervise nursing operations, conducts assessments for residents, and to provide support during change of conditions of residents.
A review of undated facility policy titled, Nursing Services indicated, It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well being .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**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 sample...
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**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 order was to give eight units of insulin to Resident 22, but LN 2 did not know why she documented the resident was given six units instead. The DON stated there could have been an effect on the resident if inaccurate medication was given.
On 11/20/24 at 12:19 P.M., an interview with LN 2 was conducted. LN 2 stated she did not know why she documented she gave six units of insulin to Resident 22 when the physician order was to give eight units. LN 2 stated it looked like she did not give the prescribed full dose of insulin to Resident 22. LN 2 stated Resident 22's blood sugar could have gone up because of this.
LN 3 was not available for interview.
2) On 11/19/24 at 1:45 P.M., an observation and interview was conducted with LN 1. LN 1 was observed documenting on the MAR dated 11/19/24 that she gave eight units of insulin to Resident 22 at 11:45 A.M. LN 1 stated she was supposed to document the medication administration right after she gave it to the resident and not wait two hours later. LN 1 stated if it was not documented right away, the staff may forget and give the resident a double dose.
On 11/20/24 at 10:09 A.M., an interview with the DON was conducted. The DON stated the staff may just forget that they already gave the medication to a resident if they did not document it right away. The DON stated the staff was supposed to document on the MAR immediately after giving the medication.
Per the facility's policy and procedure titled Medication Administration Guidelines, no date, .POLICY: 3. Each dose administered to a residents' shall be properly recorded in the residents' medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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 ...
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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 infections from Legionella.
On 11/21/24 at 10:50 A.M., an interview with the ADM was conducted. The ADM stated that they were not testing for Legionella, and they had plans to contract the service out to a company. The ADM stated the expectation was that the facility should test and monitor the water regularly for possible Legionella contamination of water sources. The ADM stated that the importance of testing for Legionella was to prevent Legionella infections in staff and residents. The ADM stated that they had just developed a Legionella policy and procedure that was not yet approved.
Review of QSO (Quality Safety Oversight Group a part of the Centers for Medicare & Medicaid Services that ensures the quality and safety of care for patients receiving Medicare and Medicaid services)-17-30 . DATE: June 02, 2017 REVISED 07.06.2018 indicated .Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water .This policy memorandum applies to .Long-Term Care .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0911
(Tag F0911)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]) accommodated no more than four residents.
This failure had the potential to limit the freedom of movement for the residents that occupied those rooms, which may place them at risk for injury.
Findings:
During initial tour on 11/18/24, five of the 25 resident rooms accommodated more than four residents:
a. Room SWD 1- 5 Residents
b. Room SWD 2- 5 Residents
c. Room SWD 3- 5 Residents
d. Room SWD 4- 5 Residents
e. room [ROOM NUMBER]- 5 Residents
During the course of the survey, those rooms did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. There were no quality of care or quality of life concerns identified that negatively affected the residents residing in those rooms.
The survey team recommends the approval of the written room waiver continuum request, dated 11/18/24, for the rooms listed in this deficiency.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident room...
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Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident rooms.
This failure had the potential to affect the resident's health and safety, and prevent the residents from maintaining their highest level of well-being by limiting the movements of those residents in their rooms.
Findings:
During initial tour, dated 11/18/24, four of the 25 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:
a. Room SWD 1 (5 beds) measured: 385.5 sq. ft. (77.1 sq. ft. per resident)
b. Room SWD 2 (5 beds) measured: 391.3 sq. ft. (78.2 sq. ft. per resident)
c. Room SWD 3 (5 beds) measured: 394.5 sq. ft. (78.9 sq. ft. per resident)
d. Room SWD 4 (5 beds) measured: 390.2 sq. ft. (78 sq. ft. per resident)
These four rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.
During an interview with the Administrator, on 11/21/24, the Administrator (ADM) confirmed the measurements for 25 of the 25 residents' rooms and four of those rooms did not meet the required 80 square feet per resident requirement.
The survey team recommends the approval of the written room waiver continuum request, dated 11/18/24, for the rooms listed in this deficiency.
Feb 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
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...
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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 prepare food because when the staff were cooking there was no dripping water. The DS stated if the kitchen was unavailable, the dining room/day room should have been utilized for food preparation. The DS stated the residents would then have meals in their rooms.
The facility did not provide a written plan for food preparation in the event of the kitchen being unavailable.
Oct 2023
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**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), f...
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**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 9:17 A.M. CNA 1 stated the facility had three residents who were DNRs and they were listed on the bulletin board in the nurse's station. CNA 1 brought me to the nurse's station and pointed out the list of the three residents on the bulletin board. The list was yellow and listed in large bold letters as NO CODE DNR RESIDENT. Resident 5 was the first name on the DNR list.
An observation, interview, and record review was conducted with LN 1 on 10/10/23 at 9:23 A.M. LN 1 stated there was a DNR list in the nurse's station and those were the only residents who were no codes. LN 1 reviewed the outside of Resident 5's chart and stated she was listed as a DNR, along with being listed on the bulletin board's DNR list. LN 1 viewed the written pink POLST form in Resident 5's chart and stated Resident 5 was listed as a Full Code. LN 1 stated the order was not clear and provided conflicting information. LN 1 stated there was a chance staff would be confused in the event of a cardiac arrest, and Resident 5's wishes might not be followed.
An interview and record review was conducted with the SSD on 10/10/23 at 2:17 P.M. The SSD stated she checked the POLST during each Interdisciplinary Team Meeting (IDT). The SSD reviewed the last IDT meeting for Resident 5 from the chart and stated it was conducted on 7/19/23. The SSD stated Resident 5 previously had a family member as her responsible party, but it changed to the conservator's office in 2022. The SSD reviewed Resident 5's clinical record, which listed her as a DNR on the outside of the chart. The SSD verified the POLST signed by the physician on 8/22/22, listed Resident 5 as a full code. The SSD stated there was a conflict in the order for code status and staff might be confused. The SSD stated she missed the change in the code status during the last IDT.
An interview was conducted with the DON on 10/12/23 at 8:45 A.M. The DON stated The POLST should reflect the physician's order. The DON stated Resident 5's clinical record was not accurate and there was the potential for Resident 5's wishes to not be followed in the event of a cardiac arrest.
According to the facility's policy titled, POLST (Physicians Order for Life Sustaining Treatment), undated, .A. The resident and or responsible party in consultation with the resident's physician will complete the POLST form based on resident's and or responsible party's choice of care in emergency situations. B. The POLST form will remain in effect unless changed by both resident and or responsible party and attending physician .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
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 R...
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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 the curtains all looked dirty and soiled. CNA 2 stated the restrooms did not present as a clean, homelike environment for the residents.
An observation and interview was conducted with housekeeper 1 (HSKP 1) on 10/10/23 at 10:24 A.M. of the Annex bathrooms. HSKP 1 stated she cleaned the bathrooms several times a day. HSKP 1 stated the bathroom were deep cleaned every month and the HSKP Supervisor (S-HSKP) kept logs of all the deep cleaned rooms. HSKP 1 viewed the interior shower curtains in both the men's and women's bathrooms and stated they were dirty and unclean. HSKP 1 stated the bathrooms did not have a clean homelike appearance.
An observation, interview, and record review was conducted with the S-HSKP on 10/10/23 at 10:50 A.M., of the Annex bathrooms deep cleaning log. The S-HSKP stated deep cleaning of the resident bathrooms should be done on a monthly basis and sooner if needed. The S-HSKP reviewed the deep cleaning log and stated the Annex bathrooms were last deep cleaned in August 2023, two months ago. The S-HSKP viewed the interior shower curtains and stated they were dirty should have been wiped down regularly with disinfectant. The S-HSKP stated the bathroom did not appear clean and homelike.
An interview was conducted with the DON on 10/12/23 at 8:45 A.M. The DON stated she expected the resident bathrooms to be inspected daily and cleaned as needed. The DON stated a clean bathroom represented a homelike environment for the residents.
According to the facility's policy, titled General Responsibility of the Housekeeping Staff, undated, .General Housekeeping Procedures are as followed: .d. bathrooms, shower rooms and toilets are cleaned 3 times daily with a germicide detergent. Shower curtains are cleaned after shower and as needed .
The facility could not provide a policy specifically related to Homelike Environment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**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 Medi...
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**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 sent to CMS, and it should have been because it was a requirement.
An interview was conducted with the DON on 10/12/23 at 8:45 A.M. The DON stated she expected all resident MDS reports to be accurate and to correctly reflect the resident's current status.
According to the CMS Resident Assessment Instrument, Version 3.0 Manual, dated October 2016, section A0310G: Unplanned Discharge; .Nursing homes and swing-bed facilities must be certain they are submitting MDS assessments to QIES ASAP (as soon as possible) for those residents who are on a Medicare and/or Medicaid certified unit .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**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 l...
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**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 interventions such as monitor for pain and encouraged to seek assistance.
On 10/11/23 the MDSN was unavailable for an interview.
An interview and record review was conducted with the ADM on 10/11/23 at 8:33 A.M. The ADM stated Resident 16 had a fall on 6/20/23 and her quarterly MDS was submitted to CMS on 7/25/23. The ADM reviewed the quarterly MDS, dated [DATE] and stated the recent fall was not captured or reported on the MDS. The ADM stated the MDSN was responsible for reviewing all the nurses' notes, physician orders, and other pertinent information to accurately assess the resident's current status. The ADM stated CMS was not provided accurate information for Resident 16's last quarterly MDS submission.
An interview was conducted with the DON on 10/12/23 at 8:45 A.M. The DON stated she expected all resident MDS reports to be accurate and to correctly reflect the resident's current status.
According to the CMS Resident Assessment Instrument, Version 3.0 Manual, dated October 2016, .Section J1800: Any Falls Since Admission/Entry: Determine the number of falls that occurred since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**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 us...
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**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 traumatic fracture .
Per the social services progress on 2/10/22 indicated .[doctor] order for a shoe lift. One of resident's [NAME][sic] are longer than the other and a shoe lift will assist resident in walking .
Per the physician order dated 3/7/22 indicated .custom shoe orthotic. Referral shoe lift aid for gait balance stability .
Per the physician order dated 5/5/22 indicated refer to [name] orthotics and prosthetic clinic for shoe lift on [right] foot [ Right] leg [is less than left status post history] of traumatic fracture.
Per the social services progress notes on 8/17/23 indicated . shoes were ready for pick up .Resident reported that the shoes fit .
There was no documented evidence of physician order on how to take care of shoe lift and monitoring shoe lift use for Resident 19.
There was no documented evidence of a physical therapy evaluation of Resident 19's mobility and use of a shoe lift.
There was no documented evidence a person-centered care plan had been developed specifically for Resident 19's shoe lift care and monitoring. However, there was a care plan dated 1/31/22, titled Potential for Injury related to fall secondary to diagnoses of dementia, traumatic brain injury, poor safety awareness, resident one leg is shorter than the other with an intervention to include use shoe lift on right foot.
On 10/11/23 at 9:23 A.M., an interview was conducted with CNA 11. CNA 11 stated Resident 19's shoe lift was for his short leg and helped him walk easier. CNA 11 stated she did not know about monitoring Resident 19's shoe lift because the social worker was the person handling the shoe lift.
On 10/11/23 at 9:27 A.M., an interview was conducted with LN 11. LN 11 stated she was not familiar with Resident 19's shoe lift.
On 10/12/23 at 9:06 A.M., a concurrent interview and record review was conducted with the DON. The DON stated there was no physician order on how to monitor Resident 19's shoe lift. The DON stated there was no physical therapy evaluation of Resident 19's mobility and use of the shoe lift. The DON stated there was no care plan for Resident 19's shoe lift. The DON stated a shoe lift was a medical device and a care plan should have been developed. The DON further stated a care plan was important to identify the needs of Resident 19 and to monitor the shoe lift to include checking for the resident foot discomfort and skin integrity. The DON stated the LNs and CNAs should have known when and what to report to physician related to Resident 19's shoe lift.
On 10/12/23 at 12:03 P.M., an interview was conducted with the DSD. The DSD stated there was no documented evidence of any education or in-service training for staff related to special equipment or device, including a shoe lift for Resident 19.
Per an undated document received from orthotics clinic by SSD with a facsimile (fax) date 10/12/23 12 P.M., entitled Shoe Lift Care Instructions indicated . Shoe lifts are orthopedic devices that are used to correct leg length discrepancies or provide additional height in one or both shoes. Proper care and maintenance of .shoe lift are essential to ensure they remain effective and comfortable .instructions .Keep Them Clean . Inspect for Wear and Tear .Store Them Properly .Replace When Necessary .Consult with a Professional .Follow Doctor's Recommendations .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**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...
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**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 Resident 26 was conducted. Resident 26 was in bed laying with the head of the bed at 15 degrees. The LAL mattress was inflated firm with the following settings noted: 400 lbs static at normal pressure.
A review of Resident 26's medical record was conducted and indicated the following:
1.
Physician's orders, dated 5/19/22, Use air mattress for skin management.
2.
Physician's orders, dated 5/19/22, Reposition resident every 2 hours.
3.
History and Physical, dated 2/26/23, resident did not have capacity to make decisions.
4.
Braden Scale, (a nursing tool used to rate the risk of skin injuries) dated 9/4/23, total score 10 - High risk for skin breakdown.
5.
Monthly weight, dated 9/1/23, 101.2 pounds.
6.
Care Plan, dated 9/8/23, Potential for impaired skin related to immobility - interventions: Low air loss mattress and turn every 2 hours.
7.
MDS (Minimum Data Set - A standardized assessment tool that measures health status) dated 9/13/23, total dependence.
A review of Resident 26's Treatment Administration Records (TAR) was conducted. There was no documented evidence of repositioning Resident 26 every 2 hours from September 1, 2023 through October 10, 2023.
On 10/10/23 at 1:07 P.M., a concurrent interview and record review was conducted with CNA 6. CNA 6 stated she was assigned to Resident 26 and was familiar with his care. CNA 6 stated Resident 26 was dependent on staff for all care. CNA 6 stated she turned Resident 26 as needed either on the right or left side. CNA 6 further stated she did not document turning for Resident 26 on her ADL (activities of daily living) sheet, as there was not a category for this. CNA 6 was not aware of a turning or repositioning policy for the facility. CNA 6 stated she could not recall receiving an in-service on turning or repositioning of residents.
On 10/11/23 at 3:05 P.M., an interview and concurrent record review was conducted with CNA 7. CNA 7 stated she was assigned to Resident 26 this shift. CNA 7 stated she turned Resident 26, as needed. CNA 7 stated she was not aware of any facility schedule or policy for turning residents. CNA 7 stated she has not received any in-services regarding turning of residents. CNA 7 stated she did not keep track of or documented turning Resident 26 as, we just do it, there is no place on the ADL task to chart it.
On 10/11/23 at 2:10 P.M., an observation, interview, and record review with LN 6 was conducted. LN 6 stated she was familiar with Resident 26 and his care. LN 6 stated Resident 26 was totally dependent on the staff for all his care. LN 6 stated the CNAs were the ones who were turning Resident 26 as needed. A review of Resident 26's TAR with LN 6 was conducted. LN 6 stated that the LNs were the ones who were supposed to document Resident 26's repositioning every 2 hours; a review of the TAR for the month of September 1, 2023 through October 11, 2023 was blank. LN 6 stated the LN staff were not ensuring this was being done. LN 6 further stated she was aware Resident 26 had a low air loss mattress on his bed, but did not know when it was put into use or how to use it. LN 6 stated she thought the hospice team was monitoring the low air loss mattress.
10/12/23 at 10:21 A.M., a concurrent observation and interview with LN 7 was conducted. LN 7 stated she was the nurse assigned to Resident 26 this shift. LN 7 stated she was familiar with Resident 26 who was dependent on staff for all his care. LN 7 stated the CNAs were supposed to turn Resident 26 every 2 hours and the LNs were supposed to be supervising them. LN 7 stated, it was the LNs who were supposed to be documenting the turning and repositioning in the TAR. A review of Resident 26's TAR indicated no documentation from September 1, 2023 through October 11, 2023. LN 7 stated, I guess this was not being done. LN 7 stated she was aware that Resident 26 had a low air loss mattress, but never received instruction on how to use it. LN 7 further stated I don't touch the mattress.
On 10/11/23 at 2:03 P.M., a concurrent interview and record review was conducted with the DSD. The DSD stated it was the expectation for the staff to follow the facility policy for repositioning dependent residents. The DSD stated most of the residents in the facility were ambulatory and Resident 26 was a special case because he was bedridden. The DSD stated she could not recall the last in-service to CNAs for repositioning dependent residents. The DSD stated it was the expectation for staff to follow the facility policy for turning residents to prevent skin breakdown. The DSD further stated she did not know if the licensed staff received an in-service for low air loss mattress and the proper setting prior to the mattress being placed into use by an outside company.
On 10/11/23 at 3:30 P.M., a concurrent interview and record review was conducted with the DON. The DON stated it was the expectation for staff to follow the facility policy for turning, repositioning and skin management to prevent skin breakdown and to document interventions in the resident's chart. The DON stated it was important to provide residents with the mentioned interventions to prevent skin breakdown, promote circulation, and preserve skin integrity. The DON stated she was unsure if an in-service had been conducted regarding the use of Resident 26's low air loss mattress, before it was put into service.
A review of the facility's policy, titled Skin Management, undated, indicated, . Preventative Skin Care .all immobile residents are turned at least Q (every) 2 hours, and PRN (as needed) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**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 ...
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**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 needed for agitation.
There was no documented evidence to indicate the Haldol PRN and Thorazine PRN were limited to 14 day use and there was no consistent physician documentation related to the necessity of the continued use beyond the 14 day limit.
There was no documented evidence of an interdisciplinary team (IDT-health care team that included the physician, nurse, social service, pharmacy, activities) meeting to determine Resident 54's continued PRN psychotropic use.
On 10/12/23 at 12:29 P.M., a concurrent interview and record review was conducted with the DON. The DON stated we should have followed the facility's policy regarding antipsychotic PRNs. The DON stated antipsychotic PRN should be reviewed and re-ordered by the physician every 14 days. The DON stated there was no IDT committee to determine, review, and document medication use for Resident 54.
On 10/12/23 at 12:10 P.M., an interview was conducted with the DSD. The DSD stated there was no documented evidence of any education or in-service training to staff related to mental illness, behavior management and PRN antipsychotic medication use.
The Pharmacy Consultant (PC) was not available for interview.
Per the facility policy titled Psychotropic Medication use, revised date 11/2017, . g. 1. All PRN Psychotropic medication orders should not exceed a 14 day length of therapy .For PRN Antipsychotic medications . a new order must be written by the MD 2. For PRN Psychotropic medications excluding Antipsychotics, the order may only be extended past 14 days by the MD . if they believe it is appropriate .Risk vs benefit rational should be documented by the physician .j. The interdisciplinary team with the assistance of the pharmacy consultant will review the resident's status and symptoms .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
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 e...
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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 inhaler. LN 11 was not observed checking the Advair diskus counter before or after administering the medication. LN 11 was asked to check the counter level after administering to Resident 52 and stated it still read 42. LN 11 re-administered the Advair inhaler to Resident 52 and stated the diskus now read 41. LN 11 stated if administered properly the counter number should go down by one. LN 11 stated she was unaware the Advair diskus counter level should be checked before and after administering, to ensure the medication was administered effectively.
Per the manufacturer's guidelines, Advair diskus has 60 doses. The counter shows how many doses are left. The number would count down by one, each time Advair diskus was used.
2. On 10/10/23 at 9:21 A.M., an observation of medications administration was conducted with LN 11. LN 11 prepared and administered seven medications to Resident 19. LN 11 administered a house supply multivitamin supplement (MVI) which contained 4.5 mg of iron.
On 10/10/23, a medication reconciliation was conducted. Resident 19 had a physician order of, .Thera M Plus (vitamin) . tablet by mouth, once a day for supplement.
On 10/10/23 a review of Resident 19's admission Face Sheet indicated Resident 19's diagnoses to include anemia (a decrease in red cells carrying oxygen to a person's body)
On 10/11/23 at 8:32 A.M., an interview was conducted with the DON. The DON was asked if the physician order Thera M Plus was equivalent to the multivitamin supplement given to Resident 19. The DON stated she would clarify Thera M Plus with the Pharmacy Consultant (PC).
On 10/11/23 at 8:53 A.M., an interview was conducted with the PC and the DON. The PC stated the facility was giving the correct medication but the wrong dose, due to the iron content. The PC stated Resident 19 would need four doses of the house MVI supplement which contained 4.5 mg of iron, to be equivalent to the correct iron content of Thera M Plus.
On 10/11/23 at 9:01 A.M., an interview was conducted with LN 11. LN 11 stated she did not administer the correct dose of Thera M Plus to Resident 19. LN 11 stated she should have followed the physician order, clarified the medication ordered with the pharmacist and notified the physician about the multivitamin supplement administered to Resident 19.
On 8/17/23 at 10:55 A.M., and interview was conducted with the DON. The DON stated LNs should follow the physician order and administer the correct dose. The DON stated LNs should have clarified with the pharmacist.
Per the facility's policy entitled Preparation and General Guidelines IIA2: Medication administration-General Guidelines effective date 8/15/2020, indicated .right dose . are applied for each medication being administered .
Per the undated facility policy entitled Policy/Procedure Subject: Physician's Orders indicated .All physician's orders will be followed as prescribed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
2. The medication room was inspected with LN 1 on 10/10/23 at 1:52 P.M. The temperature logs from May to October 2023 were reviewed. The temperature logs for the medication room had missed entries on ...
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2. The medication room was inspected with LN 1 on 10/10/23 at 1:52 P.M. The temperature logs from May to October 2023 were reviewed. The temperature logs for the medication room had missed entries on 6/20/23 AM shift (7 am-3:30 PM), 10/05/23 PM shift (3 PM-11:30 PM), and 10/09/23 NOC shift (11 PM-7:30 AM).
On 10/11/23 at 7:45 P.M., an interview and record review was conducted with the DON. The medication room temperature log for 10/5/23 and 10/9/23 were now filled in with temperature numbers and signatures. The DON stated she informed the LNs there should be no gaps in the medication room temperature log. The DON stated she herself signed the blank dates with her signature, but did not write the temperatures in. The DON stated she should have clarified with the LNs there should be no gaps/missed entries in the medication room temperature logs. The DON stated medication room temperature log book should be completed on the day the temperature was taken. The DON stated medications should be stored at specific temperatures to be effective. Therefore, without the temperature log, the facility could not ensure the medications were stored at the appropriate temperatures.
Per the facility policy titled Medication Storage in the Facility: Storage of Medications, dated 8/15/20, indicated All medications are maintained within the temperature ranges .Room Temperature 59° F to 77° F (15 °C to 25° C) .
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 unlocked medication cart on 10/10/23 at 2:05 P.M., after coming in from outside.
An observation and interview was conducted of the unlocked medication cart with the DON on 10/10/23 at 2:06 P.M. The DON observed the unlocked medication cart and stated, the cart should never be left unlocked, and the charting room needed to always be locked. The DON stated if the charting room was left unlocked, along with the medication cart, residents and staff would have access to medications, which could be harmful to them.
According to the facility's policy, titled Storage of Medications, dated August 2020, .Procedures: .B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .permitted to access medications. Medications rooms, carts, and medication supplies are locked when not attended by persons with authorized access .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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 initia...
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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 A.M., an interview with the DSS was conducted. The DSS stated the plastic bag containing the lettuce should have been sealed with tape after opening it, to prevent cross contamination. The DSS stated the lettuce should have been thrown out, since it was passed the BB date.
On 10/11/23 at 2:33 P.M., an interview with the RD was conducted. The RD stated the refrigerator should never contain any expired foods. The RD stated it was the expectation for the staff to follow the guidelines for expired foods. The RD further stated, the staff needed to follow the guidelines to prevent any potential foodborne illnesses to residents.
According to the 2017 US Food and Drug Administration Food Code, section 3-502.12, .Manufacturers use by date: It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
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 Apri...
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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 (SU); 06/17 (SA); 06/18 (SU); 06/25 (SU); 06/29 (TH); 06/30 (FR).
An interview was conducted with the Administrator (ADM), 10/09/2023 at 10 A.M. The administrator stated, The only full time RN we have is our DON, Monday through Friday. On weekends we have Licensed Vocational Nurses (LVNs), for years it's been like that here.
An interview was conducted with the DON on 10/10/2023 at 7:36 A.M., The DON stated, Staffing is determined by the census. Typically, A.M shift consist of 1 -Restorative Nursing Assistant (RNA), 2 LVNs, 8 -Certified Nursing Assistants (CNAs); P.M. shift consists of 1 RNA and 6 CNAs; Nocturnal/Night (NOC) shift consists of 1 LVN and 5 CNAs. We've never had an RN on the floor, always just the DON. Not sure what the federal requirement is but I can find out. As the DON, I'm in charge of covering all the resident's needs. The Minimum Data Set (MDS) nurse, who is a Licensed Vocational Nurse (LVN) is only here for 3-4 hours per day on weekdays, no weekends. The MDS who is an LVN covers my vacation/time off. My (DON RN) last vacation was in November 2022.
A review of the facility's undated policy, undated, titled Nursing Services, indicated, The facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.
A review of the Facility Assessment, dated December 2022, indicated, . 3.2 Staffing Plan- Based on our resident population and their needs for care and support, the following table represents the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs . Position: Registered Nurse, Total Number Needed or Average or Range: 1; Position: DON, Total Number Needed or Average or Range: 1.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
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 ...
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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 stated she would recalibrate the thermometers. When asked what is the correct temperature for the thermometer to be calibrated when in the ice water, CK 6 could not respond. When asked what CK 6 would do with the thermometer that did not calibrate correctly, CK 6 could not respond.
A review of the thermometer calibration log was conducted on 10/10/23. The thermometer calibration log was not complete for Monday 10/9/23.
On 10/10/23 at 2:14 P.M., an observation, interview, and record review with DSS was conducted. The DDS acknowledged CK 6 did not correctly calibrate the thermometer. The DSS stated thermometer calibration was done weekly by the cook. The DSS stated it was important to calibrate thermometers to make sure the food being served was safe.
On 10/11/23 at 2:47 P.M., an interview with the RD was conducted. The RD stated it was important for the staff to follow the facility policy for calibration of food thermometers to ensure the food was safe and to prevent the spread of foodborne illnesses to the residents.
A review of the facility annual competency for CK 6, dated July 26th, 2023, titled Competency Test for Cooks and DSS Staff, the document indicated, .1. What is the temperature a food thermometer must be calibrated to when using an ice bath? 32 degrees .
A review of the facility policy, dated 2018, titled Thermometer Use and Calibration the policy indicated, .1. Fill a large glass with crushed ice and add clean tap water until the glass is full and stir the mixture well .2. Put the thermometer stem into the ice water so that the sensing area is completely submerged . Do not let the stem touch the bottom or sides of the glass. The thermometer stem or probe must remain in the ice water one minute during the calibration process . 3. If the thermometer does not read 32 degrees Fahrenheit, then the thermometer must be recalibrated or discarded .
A review of the kitchen Thermometer Calibration Log, dated October 2023, indicated, .Check calibration weekly and complete thermometer calibration log
2. On 10/11/23 at 10:22 A.M., an observation and interviewed with Dietary Assistant 6 (DA 6) was conducted. The DA 6 stated the red bucket was the sanitizer and the solution was used to clean the surface of the counters. The DA 6 dipped a quaternary test strip into the red sanitizer bucket solution and no color change was noted. The DA 6 stated the color should be green, but did not know what to do if the quaternary test strip reading was not correct or what to do with the solution if the test strip reading was out of range.
On 10/11/23 at 10:38 A.M., an interview with the DSS was conducted. The DSS stated the annual competency and training is done by her or the RD. The DSS stated the staff were expected to follow the facility policy and procedure for quaternary ammonium bucket testing to ensure the effectiveness of the solution prior to cleaning counter surfaces, and to prevent food borne illnesses.
On 10/11/23 at 3:21 P.M., an interview with the RD was conducted. The RD stated the staff were expected to follow the facility policy and procedure for quaternary ammonium buckets to ensure the effectiveness of the solution and to prevent foodborne illnesses.
A review of the facility policy, dated 2018, titled, Quaternary Ammonium Log Policy, the policy indicated, .the concentration will be tested at least every shift or when the solution is cloudy. The solution will be replaced when the reading is below 200 PPM (parts per million). The replacement solution will be tested prior to usage .Alert FNS (food nutrition supervisor), Director if ammonium levels are below minimum .
3. On 10/11/22 at 1:20 P.M., a concurrent observation and interview with the Dishwasher 6 (DW 6) was conducted. The DW 6 pulled out a chlorine test strip from a container and dipped the test strip into the dishwasher machine reservoir; a color change indicated a reading of 50-100 PPM.
On 10/12/23 at 2:17 P.M., a concurrent observation and interview with the DSS was conducted. The DSS pulled out a chorine test strip from its container and dipped the test strip into the dishwasher machine reservoir; a color change indicated a reading of 50-100 PPM. The DSS was not aware that the test strip was to be placed on the dish surface. The DSS stated it was the expectation that staff follow the facility policy and procedure for testing the PPM of the dishwashing solution. The DSS further stated it was important for dishes to be sanitized in the dishwasher to prevent residents from getting foodborne illnesses.
On 10/11/23 at 3:39 P.M., an interview with the RD was conducted. The RD stated, she was not aware the test strip was to be placed on the dish surface. The RD stated it was the expectation that staff follow the facility policy and procedure for testing the PPM of the dishwashing solution. The RD further stated, it is important for dishes to be sanitized in the dishwasher to prevent residents from getting food borne illnesses.
A review of the facility policy, dated 2018, titled, Dishwashing, the policy indicated, .all dishes will be properly sanitized through the dishwasher .the Chlorine should read 50-100 PPM on dish surface in final rinse .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0911
(Tag F0911)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]) accommodated no more than four residents.
This failure had the potential to limit the freedom of movement for the residents that occupied those rooms, which may place them at risk for injury.
Findings:
During initial tour on 10/9/23, five of the 25 resident rooms accommodated more than four residents:
a. Room SWD 1- 5 Residents
b. Room SWD 2- 5 Residents
c. Room SWD 3- 5 Residents
d. Room SWD 4- 5 Residents
e. room [ROOM NUMBER]- 5 Residents
During the course of the survey, those rooms did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. There were no quality of care or quality of life concerns identified that negatively affected the residents residing in those rooms.
The survey team recommends the approval of the written room waiver continuum request, dated 10/9/23, for the rooms listed in this deficiency.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident room...
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Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident rooms.
This failure had the potential to affect the resident's health and safety, and prevent the residents from maintaining their highest level of well-being by limiting the movements of those residents in their rooms.
Findings:
During initial tour, dated 10/9/23, four of the 25 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:
a. Room SWD 1 (5 beds) measured: 385.5 sq. ft. (77.1 sq. ft. per resident)
b. Room SWD 2 (5 beds) measured: 391.3 sq. ft. (78.2 sq. ft. per resident)
c. Room SWD 3 (5 beds) measured: 394.5 sq. ft. (78.9 sq. ft. per resident)
d. Room SWD 4 (5 beds) measured: 390.2 sq. ft. (78 sq. ft. per resident)
These four rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.
During an interview with the Administrator, on 10/10/23, the Administrator confirmed the measurements for 25 of the 25 residents' rooms and four of those rooms did not meet the required 80 square feet per resident requirement.
The survey team recommends the approval of the written room waiver continuum request, dated 10/9/23, for the rooms listed in this deficiency.
Sept 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop an individualized care plan for one of eight ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop an individualized care plan for one of eight residents (Resident 22) reviewed for skin conditions when a care plan was not initiated for Resident 22's phototherapy (a light therapy that uses light waves to treat certain skin conditions) treatment.
This failure had the potential to limit the services and provision of individualized care necessary for Resident 22's needs.
Findings:
During a review of Resident 22's clinical record, the admission Face Sheet (contains demographic and medical information), indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included, bipolar disorder (a disorder associated with mood swings), Vitamin B12 deficiency anemia (abnormally large red blood cells that cannot function properly), osteoarthritis (degenerative joint disease), and thrombocytopenia (deficiency of platelets in the blood).
During a review of Resident 22's Dermatology Eval Assessment/MGMT [management] Plan (Assessment), dated November 16, 2021, the Assessment indicated, Resident 22 to start phototherapy on legs and back.
During an observation on September 20, 2022, at 1:45 PM, in Resident 22's room, Resident 22 was sitting on her bed, receiving phototherapy from dermatology (branch of medicine dealing with the skin) staff.
During an interview with a License Vocational Nurse (LVN 1) on September 21, 2022, at 2:45 PM, in Resident 22's room, LVN 1 stated Resident 22 was receiving phototherapy, per dermatologist (specialist medical doctor who manages diseases related to skin, hair, nails, and some cosmetic problems) order, due to a skin rash.
During a concurrent interview and review of Resident 22's medical records, with the Director of Nursing (DON), on September 22, 2022, at 8:23 AM, the DON was not able to find documented evidence that a care plan was initiated for Resident 22's phototherapy treatment. The DON stated it must be care planned.
During a concurrent interview and record review with the DON, on September 22, 2022, at 1:06 PM, the DON reviewed the facility's policy and procedure (P&P) titled, Care Plans, revised February 26, 2021, which indicated, It is the policy of this facility to develop an individualized person-centered comprehensive care plans for each resident that includes measurable objectives and timetables to meet a resident's medical nursing, psychosocial needs that are identified in the comprehensive assessment .5. Care plans should be initiated for any new problems identified or any change in resident's condition .These care plans must be reviewed, evaluated, accelerated or discontinued as necessary. (Falls, URI, UTI, skin, Any New Health Condition and Altercation). The DON stated the facility did not follow the policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures to ensure respirat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures to ensure respiratory care was provided for one of three residents (Resident 57) reviewed for respiratory care when Resident 57's nasal cannula (oxygen tubing) was found to be outdated.
This failure had the potential to cause negative outcome to Resident 57's physical health and wellbeing.
Findings:
During a review of Resident 57's clinical record, the face sheet (contains demographic and medical information) indicated, Resident 57 was admitted to the facility on [DATE], with diagnoses that include schizoaffective disorder (a combination of hallucinations and mood disorders), acute respiratory failure (difficulty breathing), chronic obstructive pulmonary disease (lung disease that causes obstructive airflow from the lungs), heart failure (heart muscles does not pump blood as well as it should), and encephalopathy (brain damage).
A review of Resident 57's Physician's Orders, dated February 5, 2018, indicated, OXYGEN INHALATION BY OXYGEN CONCENTRATOR CONTINOUSLY AT 2-3 LPM [liters per minute] VIA NASAL CANULA [cannula] TO KEEP O2 [oxygen] SAT [saturation] AT 92% AND ABOVE. 2LPM NASAL CAN CONTINOUS COPD/ SP [status post] PNEUMOTHORAX/@ 2LPM VIA NC [nasal cannula] PER CONCENTRATOR.
During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 2), on September 20, 2022, at 3:43 PM, in Resident 57's room, a nasal cannula attached to an oxygen concentrator (device containing pressurized oxygen which delivers oxygen to a resident) had a date showing it was last changed on August 27, 2022 (24 days ago). LVN 2 stated nasal cannulas were supposed to be changed every week on Sunday nights. LVN 2 confirmed Resident 57's oxygen tubing was outdated and should have been changed.
During a concurrent interview and record review, with the Director of Nursing (DON), on September 23, 2022, at 9:45 AM, the DON reviewed the facility's policy and procedure (P&P) titled, OXYGEN ADMINISTRATION, dated February 1, 2018, which indicated, . When not in use, nasal cannula or mask and tubing should be kept in a plastic bag. If in use, it should be changed and dated every 7 days (Sunday) and as necessary by the NOC [night shift] LVN if in use . The DON stated the policy was not followed for Resident 57. The DON further stated she expected the night shift licensed nurses to change nasal cannula on every Sunday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when a food storage container holding outdated s...
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Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when a food storage container holding outdated shredded cheese was found inside the refrigerator and was available for use.
This failure had the potential to cause foodborne illnesses to 59 medically compromised residents who receive food served by the kitchen.
Findings:
During a concurrent observation and interview with [NAME] 1, on September 20, 2022, at 10:20 AM, in the kitchen, a food storage container holding outdated shredded cheese with a label, Shredded Cheese .9-18-22 [September 18, 2022] was found on a shelve in one of the refrigerators. [NAME] 1 stated, The shredded cheese is outdated. I forgot to remove it from the refrigerator.
An interview with the Registered Dietician (RD) was conducted on September 22, 2022, at 1:50 PM. The RD stated the outdated shredded cheese should have been removed and not be left in the refrigerator together with the other food. The RD further stated, The cooks are to remove any food items with outdated labels out of the shelves every morning.
During a concurrent interview and record review with the RD, on September 23, 2022, at 9:50 AM, the RD reviewed the facility's policy and procedure (P&P), titled, STORAGE OF FOOD AND SUPPLIES, dated 2017, which indicated, Policy: Food and supplies will be stored properly and in a safe manner . The RD stated the facility did not have a specific policy on labeling and dating of foods.
A review of the Food and Drug Administration Food Code 2017, 3-701.11, indicated, Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food. (A) A FOOD that is unsafe, ADULTERED, or not honestly presented as specified under $ 3-101.11 shall be discarded or reconditioned according to ab APPROVED procedure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a physician's order for phototherapy (a light ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a physician's order for phototherapy (a light therapy that uses light waves to treat certain skin conditions) was transcribed by a licensed nurse in accordance with the facility's policy and procedure for one of eight residents (Resident 22) reviewed for skin condition.
This failure had the potential to result in an unidentified complication and/or worsening of skin condition, placing Resident 22 at risk for further injuries.
Findings:
During an observation on September 20, 2022, at 1:45 PM, in Resident 22's room, Resident 22 was sitting on her bed, receiving phototherapy from dermatology (branch of medicine dealing with the skin) staff.
During an interview with the License Vocational Nurse (LVN 1) on September 21, 2022, at 2:45 PM, in Resident 22's room, LVN 1 stated Resident 22 was receiving phototherapy, per dermatologist (specialist medical doctor who manages diseases related to skin, hair, nails, and some cosmetic problems) order, due to a skin rash.
During a review of Resident 22's clinical record, the admission Face Sheet (contains demographic and medical information) indicated, Resident 22 was admitted to the facility on [DATE], with diagnoses which included, bipolar disorder (a disorder associated with mood swings), Vitamin B12 deficiency anemia (abnormally large red blood cells that cannot function properly), osteoarthritis (degenerative joint disease), and thrombocytopenia (deficiency of platelets in the blood).
During a review of Resident 22's Dermatology Eval Assessment/MGMT [management] Plan (Assessment), dated November 16, 2021, the Assessment indicated, Resident 22 to start phototherapy on legs and back.
During a concurrent interview and record review with the Director of Nursing (DON), on September 22, 2022, at 8:31 AM, the DON reviewed Resident 22's clinical record, and was not able to find a physician's order for phototherapy. The DON stated there must be an order for Resident 22's phototherapy treatment.
During a concurrent interview and record review with the DON, on September 22, 2022, at 10:29 AM, the DON reviewed the facility's undated policy and procedure (P&P) titled, Physician's Order, which indicated, All resident medications/treatments must be ordered a licensed physician. The DON stated, the policy was not followed.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0911
(Tag F0911)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]) accommodated no more than four residents.
This failure had the potential to limit the freedom of movement of the residents that occupied the rooms, which may place them at risk for injury.
Findings:
During an interview with the Administrator, on September 21, 2022, at 8:15 AM, the Administrator stated the facility had five resident rooms with more than four residents residing in the room (Rooms SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]).
During a concurrent observation and interview with the Maintenance Supervisor (MS 1) and the Maintenance Staff (MS 2), on September 21, 2022, at 10:53 AM, five of the 25 resident rooms accommodated more than four residents:
i. Room SWD 1- 5 Residents
ii. Room SWD 2- 5 Residents
iii. Room SWD 3- 5 Residents
iv. Room SWD 4- 5 Residents
v. room [ROOM NUMBER]- 5 Residents
During the course of the survey, these rooms did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. There were no quality of care or quality of life concerns identified that negatively affected the residents residing in those rooms.
The Department recommends a continuation of the waiver as set forth in the CMS letter.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident room...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident rooms.
This failure had the potential to affect the resident's health and safety, and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms.
Findings:
During an interview with the Administrator, on September 21, 2022, at 8:15 AM, the Administrator stated the facility had four of 25 resident rooms (Room SWD 1, SWD 2, SWD 3, and SWD 4) which had less than the required square footage (80 sq. ft. of livable space).
During an environmental tour with the Maintenance Supervisor (MS 1) and Maintenance Staff (MS 2), on September 21, 2022, at 10:53 AM, four of the 25 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:
i. Room SWD 1 (5 beds) measured: 385.5 sq. ft. (77.1 sq. ft. per resident)
ii. Room SWD 2 (5 beds) measured: 391.3 sq. ft. (78.2 sq. ft. per resident)
iii. Room SWD 3 (5 beds) measured: 394.5 sq. ft. (78.9 sq. ft. per resident)
iv. Room SWD 4 (5 beds) measured: 390.2 sq. ft. (78 sq. ft. per resident)
These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.
During an interview with the Administrator, on September 21, 2022, at 11:10 AM, the Administrator confirmed the measurements for 25 of the 25 residents' rooms and four of these did not meet the required 80 square feet per resident requirement.
The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
Concerns
- • 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Hillcrest Manor Sanitarium's CMS Rating?
CMS assigns HILLCREST MANOR SANITARIUM an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Hillcrest Manor Sanitarium Staffed?
CMS rates HILLCREST MANOR SANITARIUM's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Hillcrest Manor Sanitarium?
State health inspectors documented 27 deficiencies at HILLCREST MANOR SANITARIUM during 2022 to 2025. These included: 21 with potential for harm and 6 minor or isolated issues.
Who Owns and Operates Hillcrest Manor Sanitarium?
HILLCREST MANOR SANITARIUM is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 98 certified beds and approximately 60 residents (about 61% occupancy), it is a smaller facility located in NATIONAL CITY, California.
How Does Hillcrest Manor Sanitarium Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, HILLCREST MANOR SANITARIUM's overall rating (3 stars) is below the state average of 3.1 and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Hillcrest Manor Sanitarium?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Hillcrest Manor Sanitarium Safe?
Based on CMS inspection data, HILLCREST MANOR SANITARIUM has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Hillcrest Manor Sanitarium Stick Around?
HILLCREST MANOR SANITARIUM has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Hillcrest Manor Sanitarium Ever Fined?
HILLCREST MANOR SANITARIUM has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Hillcrest Manor Sanitarium on Any Federal Watch List?
HILLCREST MANOR SANITARIUM is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.