Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**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,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
055975
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055975
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillcrest Manor Sanitarium
1889 National City Blvd.
National City, CA 91950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
055975
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055975
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillcrest Manor Sanitarium
1889 National City Blvd.
National City, CA 91950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055975
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillcrest Manor Sanitarium
1889 National City Blvd.
National City, CA 91950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055975
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillcrest Manor Sanitarium
1889 National City Blvd.
National City, CA 91950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055975
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillcrest Manor Sanitarium
1889 National City Blvd.
National City, CA 91950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0911
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016,
rooms hold no more than 2 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, 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055975
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hillcrest Manor Sanitarium
1889 National City Blvd.
National City, CA 91950
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
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.
Residents Affected - Some
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 7 of 7
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F911 - Accommodate no more than four residents
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
FAQ · About this visit
Common questions about this visit
What happened during the September 23, 2022 survey of Hillcrest Manor Sanitarium?
This was a inspection survey of Hillcrest Manor Sanitarium on September 23, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Hillcrest Manor Sanitarium on September 23, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.