Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
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.
Residents Affected - Some
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 .
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 5
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
11/21/2024
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**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:
Residents Affected - Some
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 2 of 5
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
11/21/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
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).
Residents Affected - Some
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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 3 of 5
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
11/21/2024
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 4 of 5
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
11/21/2024
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055975
If continuation sheet
Page 5 of 5
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Back to topCitations
5 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.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F880 - Infection Control
Provide and implement an infection prevention and control program.
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 November 21, 2024 survey of Hillcrest Manor Sanitarium?
This was a inspection survey of Hillcrest Manor Sanitarium on November 21, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Hillcrest Manor Sanitarium on November 21, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."
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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