Health inspection·September 15, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 (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 2 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 09/15/2025 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)